A nurse is assessing a client who was brought to the emergency department with an ankle injury.
Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

3+ palpable pedal pulses below the affected injury site.

Full range of motion at the site of injury.

Sanguineous drainage at the site of injury.

Localized warmth at the site of injury.

Answer and Explanation

The Correct Answer is D

Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.

Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.

Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.

Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.

Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.

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Correct Answer is C

Explanation

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

A. Place the client on a cardiac monitor. B. Administer a laxative as ordered. C. Place the client on seizure precautions. D. Restrict high potassium foods.

Correct Answer is A

Explanation

This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.

Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.

Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.

Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels.

Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.

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A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

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A nurse is assessing a client who was brought to the emergency department with an ankle injury.
Which of the following manifestations should the nurse identify as localized inflammation of the tissues?