Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation:

is a protective response

is a disease process

produces tissue damage

is a result of bacteria

Answer and Explanation

The Correct Answer is A

A. Is a protective response – Inflammation is a natural immune response that helps contain injury and promote healing, regardless of infection.

B. Is a disease process – Inflammation itself is not a disease; it is a response to injury, infection, or irritation.

C. Produces tissue damage – While excessive or chronic inflammation can cause tissue damage, inflammation itself is not inherently destructive.

D. Is a result of bacteria – Inflammation can be caused by bacteria, viruses, trauma, or autoimmune conditions, not just bacterial infection.

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Correct Answer is C

Explanation

A. After palpating the abdomen – Palpation may alter bowel sounds by stimulating peristalsis, leading to inaccurate findings.

B. After checking for kidney tenderness – Checking for kidney tenderness (costovertebral angle tenderness) is unrelated to bowel auscultation and should not precede it.

C. Before percussing the abdomen – Auscultation should be done before percussion and palpation to avoid artificially stimulating bowel sounds.

D. Before inspecting the abdomen – Inspection should always come before auscultation to visually assess the abdomen for distension, symmetry, and discoloration before listening.

A. Press the skin over the client's ankle bone B. Lightly palpate the skin using the fingertips C. Grasp a fold of skin on the client's forearm or near the sternum D. Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen

Correct Answer is C

Explanation

A. Press the skin over the client's ankle bone. – The skin over bony prominences does not provide an accurate assessment of turgor due to reduced subcutaneous tissue in elderly clients.

B. Lightly palpate the skin using the fingertips. – Light palpation assesses texture and moisture but does not evaluate skin turgor.

C. Grasp a fold of skin on the client’s forearm or near the sternum. – Skin turgor is best assessed by gently pinching the skin on the forearm or sternum. Delayed return to normal indicates dehydration or decreased skin elasticity due to aging.

D. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. – This describes petechiae, which indicate capillary fragility or bleeding disorders, not skin turgor.

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Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Correct Answer is C

Explanation

The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

The study of all factors involved in the development of the disease or the cause of the disease is termed:

An abnormal accumulation of fluid in the interstitial spaces is described as:

Discoloration of an area of the skin or mucous membranes caused by extravasation of blood into subcutaneous tissue is termed:

The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

The nurse is meeting a patient for the first time. The initial step in initiating a nurse-patient relationship is for the nurse to:

The nurse is collecting data during an initial assessment. The patient tells the nurse, "i have a tremendous headache and my stomach is upset." These findings are called:

An abnormal rapid rate of breathing seen in many disease conditions is called:

An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is called: