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. Macule: A macule is a flat, discolored area of skin that is smaller than 1 centimeter in diameter and does not contain fluid.
B. Vesicle: A vesicle is a raised, fluid-filled lesion smaller than 1 centimeter in diameter.
Examples include blisters caused by conditions such as herpes simplex virus or contact dermatitis.
C. Papule: A papule is a raised, solid lesion smaller than 1 centimeter in diameter that does not contain fluid. Examples include pimples or insect bites.
D. Wheal: A wheal is a raised, red area of skin that is often accompanied by itching. It is typically caused by an allergic reaction and may have irregular borders.
Correct Answer is D
Explanation
A. Skin lesions are seen as solid predictors of the general health state: While skin lesions can provide valuable information about a patient's health, they are not the only indicator. Changes in the skin can indicate various health conditions, not just lesions.
B. The patient's psychological health is best predicted by the skin: While changes in the skin can sometimes be associated with psychological health conditions, they are not the sole predictors. Psychological health is assessed through a comprehensive evaluation, including observation, interview, and assessment tools.
C. Detection of skin cancer is the only reason to assess the client's skin: While skin cancer detection is an important aspect of skin assessment, it is not the only reason. Skin assessment provides valuable information about overall health, hydration status, circulation, and potential systemic conditions.
D. The skin is a good communicator regarding the client's overall health: The skin can provide valuable clues about a patient's overall health status. Changes in skin color, texture, moisture, and integrity can indicate underlying health conditions, nutritional deficiencies, circulation problems, or systemic diseases. Therefore, focusing on any changes noted in the patient's skin is essential for comprehensive assessment and early detection of potential health issues.
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