A nurse is assessing a client who has a puncture wound on his foot.
Which of the following findings is a manifestation of acute osteomyelitis?
Localized erythema.
Numbness of toes on the affected foot.
Bradycardia.
Hypothermia.
The Correct Answer is A
Choice A rationale
Localized erythema, along with warmth, swelling, and tenderness, is a cardinal sign of acute osteomyelitis. This inflammation is a direct result of the host's immune response to bacterial invasion within the bone. The increased blood flow to the affected area, mediated by inflammatory cytokines and vasodilatation, causes the characteristic redness and heat observed during the acute phase of infection.
Choice B rationale
Numbness of the toes on the affected foot is more indicative of neurological involvement or peripheral neuropathy rather than a primary manifestation of acute osteomyelitis. While severe swelling from osteomyelitis could potentially impinge on nerves, numbness is not a direct or common initial symptom of bone infection. Acute osteomyelitis primarily presents with inflammatory signs and systemic symptoms.
Choice C rationale
Bradycardia, an abnormally slow heart rate (typically below 60 beats per minute for adults), is not a typical manifestation of acute osteomyelitis. Acute infections, including osteomyelitis, commonly trigger a systemic inflammatory response, which usually leads to tachycardia, an elevated heart rate, as the body attempts to compensate for increased metabolic demands and fight the infection.
Choice D rationale
Hypothermia, a core body temperature below 35°C (95°F), is not a common manifestation of acute osteomyelitis. Instead, clients with acute osteomyelitis frequently present with fever, indicating a systemic inflammatory response to the infection. Hypothermia might occur in severe sepsis or septic shock, but it is not a direct or initial symptom of localized bone infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
Step 1 is to calculate the flow rate in gtt/min. (100 mL ÷ 60 min) × 60 gtt/mL = 100 gtt/min. The nurse should set the IV flow rate to deliver 100 gtt/min.
Correct Answer is C
Explanation
Choice A rationale
Having the client identify specific smells assesses the function of the olfactory nerve, which is Cranial Nerve I. This nerve is responsible for the sense of smell and is tested independently of the facial nerve, which governs motor functions of the face and taste sensation.
Choice B rationale
Checking the client's visual acuity using a Snellen chart assesses the optic nerve, Cranial Nerve II. This nerve transmits visual information from the retina to the brain. Its function is distinct from that of Cranial Nerve VII, which controls facial muscle movements and taste.
Choice C rationale
Observing for facial symmetry while the client smiles directly assesses the motor function of Cranial Nerve VII, the facial nerve. This nerve innervates the muscles of facial expression. Asymmetry or weakness indicates potential damage or dysfunction of this specific cranial nerve. Normal range includes symmetrical movement.
Choice D rationale
Whispering in one of the client's ears while occluding the other assesses the vestibulocochlear nerve, Cranial Nerve VIII. This nerve is responsible for hearing and balance. It is not involved in controlling facial expressions or taste sensation, which are functions of Cranial Nerve VII.
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