The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?

Exudate

Pain

Hyperthermia

Hardening of the tissue

Answer and Explanation

The Correct Answer is C

A.   Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.
While exudate may be present in infected wounds, it is not a systemic response.
B.   Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.
C.   Hyperthermia: Hyperthermia, or an elevated body temperature (fever), is a common systemic response to infection, including wound infections. It indicates the body's immune response to the infection.
D.   Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.

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Correct Answer is B

Explanation

A. Droplet: Droplet precautions are used for diseases transmitted by large droplets expelled during coughing, sneezing, or talking, such as influenza or pertussis.
B. Contact: Contact precautions are used for diseases transmitted by direct contact with the
patient or indirect contact with contaminated objects or surfaces, such as MRSA or Clostridium difficile (C. diff).
C. Protective: Protective precautions are not a standard category of transmission-based precautions. It is not applicable in this context.
D. Airborne: Airborne precautions are used for diseases transmitted by small particles suspended in the air, such as tuberculosis or measles.

A. A 49-year-old who works in food services B. An 88-year-old who lives in an apartment for senior citizens C. A 26-year-old with three young children D. A 15-year-old who plays ice hockey

Correct Answer is B

Explanation

A. A 49-year-old who works in food services: While individuals working in food services may be at risk of exposure to influenza, they are not in the highest priority group. Age and underlying health conditions are typically prioritized over occupational risk factors.

B. An 88-year-old who lives in an apartment for senior citizens: Older adults, especially those living in congregate settings like senior citizen apartments, are at higher risk of complications from influenza. Therefore, the 88-year-old should have the highest priority to receive the vaccine.

C. A 26-year-old with three young children: While having young children may increase the risk of exposure to influenza, younger adults without underlying health conditions are generally at lower risk of severe complications compared to older adults.

D. A 15-year-old who plays ice hockey: While participation in activities like ice hockey may increase the risk of exposure to respiratory infections, age and health status are more significant factors in determining priority for influenza vaccination.

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The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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