Mary, a 45-year-old woman, comes into the clinic complaining of a swollen and painful toe after stubbing it on a furniture leg. The nurse explains that the pain is most likely due to what mechanism in the inflammatory response?

Release of enzymes that irritate the tissues.

Edema compressing nerve endings.

Heat generated during the process of lysis.

Accumulation of acidic waste from dying cells.

Answer and Explanation

The Correct Answer is B

A.   This mechanism is more relevant in conditions like pancreatitis or tissue injury involving enzyme release, not specifically in traumatic inflammation.
B.   Inflammation leads to increased vascular permeability and fluid accumulation (edema), which can compress nerve endings and cause pain.
C.   Lysis refers to the breakdown of cells, which may release heat, but this is not typically a significant factor in localized inflammation from trauma.
D.   Acidic waste accumulation occurs in cell death processes like necrosis, but it's not the primary mechanism causing pain in traumatic inflammation.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Avoid giving Paul a diet rich in fresh fruits, as they may contain harmful microorganisms that could cause infections. Instead, give him cooked or canned fruits that are safe to eat.
B. Strict adherence to Standard Precautions, which include hand hygiene, wearing gloves, gowns, and masks when necessary, is crucial to prevent infections in immunocompromised patients.
C. Do not place live plants in Paul's room, as they may harbor mold spores that could cause respiratory problems for Paul. Instead, use artificial plants or flowers that are easy to clean and disinfect.

D. Protective isolation measures, such as placing the patient in a private room and using appropriate barriers, can help minimize the risk of exposure to infectious agents.
E. Installing high-efficiency particulate air filters can help reduce airborne pathogens and allergens, which is important for patients with compromised immune systems.

A. Lithotomy position B. Left lateral (Sims) position C. Bent forward with hips flexed D. Standing position

Correct Answer is B

Explanation

A. Lithotomy position requires the patient to lie on his back with his legs raised and spread apart, which may be difficult for a nonambulatory patient and may cause pressure on his lower back and pelvis.
B. This position allows for easy access to the rectum and prostate without causing discomfort or strain to the patient or examiner. The patient lies on his left side with his right leg flexed at the hip and knee and his left leg slightly flexed at the hip and straight at the knee.
C. Bent forward with hips flexed requires the patient to stand up and lean over a table or chair, which may also be challenging for a nonambulatory patient and may cause dizziness or loss of balance.

D. Standing position requires the patient to stand up straight with his feet apart, which may not provide adequate exposure or comfort for the examination.

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Mary, a 45-year-old woman, comes into the clinic complaining of a swollen and painful toe after stubbing it on a furniture leg. The nurse explains that the pain is most likely due to what mechanism in the inflammatory response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Nurse Alex is assigned to care for Paul, a patient with severely reduced neutrophil counts. Which considerations should be included in Paul's care plan? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

John, a 65-year-old man, is nonambulatory and presents with complaints of rectal pain and problems with urination. What is the best position to examine John's rectum and prostate?

Correct Answer is B

Explanation

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