The nurse assesses the wound of a client who received sutures for a laceration of the hand two days ago. Which finding is a normal inflammatory response?

Shivering.

Purulent drainage.

Temperature of 102° F (37.8° C).

Redness and localized heat.

Answer and Explanation

The Correct Answer is D

A) Shivering:

Shivering is not a normal inflammatory response to wound healing. It may indicate systemic symptoms such as fever or chills, which could be indicative of infection or other complications.

B) Purulent drainage:

Purulent drainage (pus) is often a sign of infection rather than a normal inflammatory response to wound healing. While some serous or serosanguinous drainage may be expected initially, purulent drainage suggests an abnormal response.

C) Temperature of 102° F (37.8° C):

A temperature of 102° F (37.8° C) is indicative of fever, which can occur in response to infection or inflammation. While fever is part of the inflammatory response, it is not necessarily considered a normal finding in the context of wound healing and may indicate an abnormal response such as infection.

D) Redness and localized heat:

Correct. Redness (erythema) and localized heat are typical signs of the inflammatory phase of wound healing. Inflammation is a normal response to tissue injury and is characterized by increased blood flow to the area, resulting in redness and warmth. These signs indicate that the body's immune response is active and working to repair the injured tissue.

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Correct Answer is C

Explanation

A) Small, skin-colored, pedunculated papules in areas of skin folds and on other areas as skin tags:

This description is more characteristic of acrochordons (skin tags), which are benign skin growths often found in skin folds. Skin tags are typically not associated with acne vulgaris.

B) Hyperpigmented areas that vary in form and color and are slightly elevated from the skin:

This description may be indicative of post-inflammatory hyperpigmentation, which can occur after resolution of acne lesions. However, it does not represent the primary pathological findings observed in acne vulgaris.

C) Hyperactive sebaceous areas forming comedones, papules, pustules on the face, neck, and upper back:

Correct. Acne vulgaris is characterized by hyperactive sebaceous glands, leading to the formation of comedones (blackheads and whiteheads), papules, and pustules. These lesions commonly occur on the face, neck, and upper back due to the high density of sebaceous glands in these areas.

D) Sharply demarcated silvery scaling plaques with underlying redness on the elbows and knees:

This description is more indicative of psoriasis, a chronic autoimmune skin condition characterized by silvery scaling plaques and inflammation. Psoriasis typically affects extensor surfaces such as the elbows and knees, rather than the areas commonly affected by acne vulgaris.

A. Deficiency of factors VIII or IX. B. Diminished amount of vitamin K. C. Decreased amount of platelets. D. Missing factors V and VII.

Correct Answer is A

Explanation

A) Deficiency of factors VIII or IX.

Hemophilia is a genetic disorder characterized by deficient or defective clotting factors, specifically factors VIII (hemophilia A) or IX (hemophilia B). These clotting factors are essential for the formation of stable blood clots. Therefore, if hemophilia is present, the deficiency of factors VIII or IX can lead to impaired clot formation and prolonged bleeding.

B) Diminished amount of vitamin K:

Vitamin K deficiency can lead to impaired blood clotting due to inadequate synthesis of clotting factors in the liver. However, hemophilia is specifically associated with deficiencies in factors VIII or IX, not vitamin K.

C) Decreased amount of platelets:

Platelets play a crucial role in primary hemostasis and initial platelet plug formation at the site of vascular injury. While decreased platelet count or dysfunction can lead to bleeding disorders such as thrombocytopenia or platelet function disorders, hemophilia specifically involves deficiencies in clotting factors, not platelets.

D) Missing factors V and VII:

Factor V and VII are other clotting factors involved in the coagulation cascade, but they are not deficient in hemophilia. Hemophilia is specifically characterized by deficiencies in factors VIII (hemophilia A) or IX (hemophilia B).

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The nurse assesses the wound of a client who received sutures for a laceration of the hand two days ago. Which finding is a normal inflammatory response?

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