A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

Dry, occasional cough.

Temperature or Febrile 103 degrees F (39.4 degrees C)

Clear, watery drainage from the nose

Scratchy throat

Answer and Explanation

The Correct Answer is B

A.   Dry, occasional cough: A dry, occasional cough is a common symptom of upper respiratory infections and may not necessarily indicate a complication.
B.   Temperature or Febrile 103 degrees F (39.4 degrees C): A high fever (over 100.4 degrees F or 38 degrees C) is a concerning symptom that may indicate the development of a complication such as pneumonia or a secondary bacterial infection.
C.   Clear, watery drainage from the nose: Clear, watery drainage from the nose is typically associated with viral upper respiratory infections and may not necessarily indicate a complication.
D.   Scratchy throat: A scratchy throat is a common symptom of upper respiratory infections and may not necessarily indicate a complication.

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Correct Answer is D

Explanation

A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.

A. Exudate B. Pain C. Hyperthermia D. Hardening of the tissue

Correct Answer is C

Explanation

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.

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A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessments should be performed to monitor for impaired tissue integrity?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

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