The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?
Exudate
Pain
Hyperthermia
Hardening of the tissue
The Correct Answer is C
A. Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.
While exudate may be present in infected wounds, it is not a systemic response.
B. Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.
C. Hyperthermia: Hyperthermia, or an elevated body temperature (fever), is a common systemic response to infection, including wound infections. It indicates the body's immune response to the infection.
D. Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A person with diabetes who requires hospitalization for cellulitis: Cellulitis may not necessarily be a healthcare-associated infection unless it developed as a complication during the hospitalization.
B. Pneumonia in a hospitalized patient: Pneumonia acquired during a hospital stay is considered a healthcare-associated infection (HAI) because it develops after 48 hours of hospital admission.
C. Chronic urinary tract infection for a homebound patient: A chronic urinary tract infection in a homebound patient is not automatically considered a healthcare-associated infection unless it can be directly linked to healthcare interventions or devices.
D. A sexually transmitted infection in a healthy young adult: Sexually transmitted infections are not healthcare-associated infections as they are typically acquired through sexual contact rather than healthcare settings.
Correct Answer is ["B","D","E"]
Explanation
A. Hypoglycemic: Hypoglycemia is not typically considered a sign or symptom of sepsis. In sepsis, blood glucose levels may fluctuate, but hypoglycemia is less common.
B. Elevated White Blood Count: An elevated white blood count (leukocytosis) is a common sign of sepsis, indicating the body's immune response to infection.
C. Pruritus: Pruritus, or itching, is not typically associated with sepsis. Itching may occur in certain skin conditions or allergic reactions but is not a hallmark sign of sepsis.
D. Hypotension: Hypotension, or low blood pressure, is a serious sign of sepsis and can indicate septic shock, a life-threatening complication.
E. Altered Mental Status: Altered mental status, such as confusion, disorientation, or decreased level of consciousness, can occur in sepsis due to systemic inflammation and impaired perfusion to the brain.
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