The characteristic vascular changes at the site of an injury produce: (Select all that apply)
Increased permeability and leakage
Blood vessel constriction after dilation
Pallor and swelling
None of the above
Tightening of the capillary endothelial cell junctions
Correct Answer : A,B,C
Choice A reason: Increased permeability and leakage occur at an injury site due to histamine and cytokine release, causing endothelial gaps. This allows plasma and immune cells to enter tissues, promoting inflammation and edema, making this a correct vascular change.
Choice B reason: Blood vessels initially constrict to limit bleeding, then dilate to increase blood flow, delivering immune cells and nutrients. This biphasic response (constriction followed by dilation) is a hallmark of acute injury, making this a correct vascular change.
Choice C reason: Pallor occurs from initial vasoconstriction, reducing blood flow, followed by swelling from increased permeability and fluid leakage. These are typical injury responses, reflecting vascular and tissue changes, making this a correct observation.
Choice D reason: “None of the above” is incorrect, as increased permeability, biphasic vessel response, and pallor with swelling are well-documented vascular changes at injury sites. These align with the inflammatory process, making this an invalid choice.
Choice E reason: Tightening of capillary endothelial junctions does not occur during acute injury. Junctions loosen due to inflammatory mediators, increasing permeability, not tightening, which would limit leakage, making this an incorrect vascular change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Retching is the involuntary attempt to vomit, involving abdominal muscle contractions without expelling stomach contents. The patient is actively expelling contents, which defines vomiting, not just the effort of retching, making this an incorrect term for documentation.
Choice B reason: Expectorate refers to coughing up and spitting out mucus or sputum from the respiratory tract. The patient is expelling stomach contents, not respiratory secretions, making expectorate an incorrect term for this gastrointestinal event.
Choice C reason: Regurgitation is the passive return of undigested food or liquid from the stomach or esophagus, often without force. The forceful expulsion of stomach contents described indicates vomiting, not regurgitation, making this an incorrect documentation term.
Choice D reason: Vomiting is the forceful expulsion of stomach contents through the mouth, driven by coordinated abdominal and diaphragmatic contractions. The patient’s active expulsion into a basin matches this definition, making vomiting the correct term for documentation.
Correct Answer is C
Explanation
Choice A reason: Pyuria, urgency, and frequency are typical UTI symptoms, but elderly patients often present with atypical signs like confusion. Confusion is more prominent in this age group, so this is less specific and incorrect.
Choice B reason: Dysuria, frequency, and suprapubic pain are common UTI symptoms, but elderly patients may show confusion instead of classic signs. Confusion and frequency are more likely, so this is incorrect.
Choice C reason: In elderly patients (85 years), UTIs often cause confusion due to altered mental status, alongside frequency. Atypical symptoms like confusion are common, making this the correct manifestation for this age group.
Choice D reason: Hematuria and flank pain suggest complicated UTIs or kidney issues, not typical in elderly UTI presentation. Confusion and frequency are more expected, so this is incorrect.
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