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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Leukotrienes are inflammatory mediators derived from arachidonic acid metabolism, primarily produced by leukocytes (white blood cells) such as mast cells, eosinophils, and basophils. In the context of asthma, leukotrienes play a significant role in the pathophysiology of the disease by contributing to airway inflammation and bronchoconstriction. Here's a breakdown of their immune response:
A) Produce the sensation of itching:
Leukotrienes are not directly involved in producing the sensation of itching. Itching is often associated with histamine release rather than leukotrienes.
B) Tighten airway and produce mucous:
Correct. Leukotrienes are potent bronchoconstrictors that cause smooth muscle contraction in the airways, leading to narrowing (constriction) of the bronchioles. Additionally, they stimulate the secretion of mucus from goblet cells in the airway epithelium, contributing to airway obstruction and mucus production, which are characteristic features of asthma exacerbations.
C) Causes formation of bradykinin:
Bradykinin is a peptide mediator that is generated from the plasma protein kininogen and is involved in vasodilation, pain sensation, and inflammation. Leukotrienes are not directly responsible for the formation of bradykinin.
D) Serves as a receptor for antigen:
Leukotrienes do not serve as receptors for antigens. Instead, they are lipid mediators released in response to various stimuli, including allergens, infections, and irritants, and they act on specific receptors (e.g., leukotriene receptors) to exert their effects, such as bronchoconstriction and inflammation
Correct Answer is B
Explanation
Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease, is a progressive neurodegenerative disorder affecting motor neurons in the brain and spinal cord. Understanding the pathophysiological process of ALS is crucial for providing accurate information about the disease prognosis to the client. Here's why option B is the correct choice:
A) It occurs as a complication of a spinal cord injury:
This statement is incorrect. ALS is not a complication of a spinal cord injury. While both conditions involve motor neuron dysfunction, they have different etiologies and pathophysiological processes. ALS is characterized by the degeneration of motor neurons in the brain and spinal cord, leading to muscle weakness and atrophy, whereas spinal cord injury results from trauma to the spinal cord.
B) Muscle weakness is progressive, degenerative, and fatal:
Correct. ALS is characterized by progressive degeneration of motor neurons, leading to muscle weakness, atrophy, and eventual paralysis. The disease is relentless and fatal, typically within 2 to 5 years of diagnosis, although survival can vary widely among individuals. As motor neurons degenerate, voluntary muscle control is lost, eventually affecting the ability to speak, swallow, breathe, and move. Respiratory failure is the most common cause of death in ALS patients.
C) Mental status changes occur late in the disease:
While cognitive and behavioral changes can occur in some individuals with ALS, particularly in the later stages of the disease, they are not universal. ALS primarily affects motor neurons, leading to progressive muscle weakness and paralysis. However, some individuals may experience frontotemporal dementia (FTD), a type of cognitive impairment characterized by changes in behavior, personality, and language.
D) Autonomic nervous system and sensory changes occur:
ALS primarily affects motor neurons rather than sensory neurons or the autonomic nervous system. Sensory symptoms such as numbness, tingling, or loss of sensation are not typical features of ALS. Autonomic dysfunction, including changes in heart rate, blood pressure, or bowel and bladder function, is not a prominent feature of ALS.
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