The protective response of body tissues to irritation, injury or pathogens is:

infection

ecchymosis

erythema

Inflammation

Answer and Explanation

The Correct Answer is D

A. Infection. – Infection refers to the invasion of body tissues by microorganisms, while inflammation is the body’s response to injury or infection.

B. Ecchymosis. – Ecchymosis refers to bruising caused by blood leakage under the skin, not a protective response.

C. Erythema. – Erythema is redness of the skin due to increased blood flow, which is a symptom of inflammation but not the process itself.

D. Inflammation. – Inflammation is the body’s protective response to injury, infection, or irritation. It involves increased blood flow, immune cell activation, and chemical mediators to promote healing.

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Correct Answer is ["A"]

Explanation

A. Peripheral pulses that can be assessed include brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial. – These are key arterial pulse points used to assess circulation and vascular health.

B. Assess the radial pulse rate by counting the pulsations for 60 seconds. – Counting for a full minute provides the most accurate heart rate measurement, especially if irregularities are present.

C. On a person with good cardiac function and distal perfusion, capillary refill should take less than 6 seconds. – Normal capillary refill time (CRT) is ≤2 seconds. A refill time >2 seconds suggests poor perfusion.

D. The strength of the pulse can be measured using the following scale: 0, 1+, 2+, and 3+. –. The standard pulse grading scale ranges from 0 to 4+.

A. percussion B. palpation C. auscultation D. Inspection

Correct Answer is B

Explanation

A. Percussion – Percussion helps assess the size, location, and density of organs but is not the primary technique for identifying tenderness.

B. Palpation – Palpation involves using the hands to assess for tenderness, swelling, temperature changes, and masses. It is the most effective method for detecting areas of tenderness.

C. Auscultation – Auscultation involves listening to internal body sounds, such as heart, lung, and bowel sounds, and does not assess tenderness.

D. Inspection – Inspection is visual observation of the body for abnormalities but does not involve physically assessing for tenderness.

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The protective response of body tissues to irritation, injury or pathogens is:

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Naxlex Comprehensive Predictor Exams

Which would be included in an assessment of the peripheral vascular system? (select all that apply)

Correct Answer is ["A"]

Explanation

When performing a physical examination of the patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness. This technique is:

Correct Answer is B

Explanation

Discoloration of an area of the skin or mucous membranes caused by extravasation of blood into subcutaneous tissue is termed:

The nurse is collecting data during an initial assessment. The patient tells the nurse, "i have a tremendous headache and my stomach is upset." These findings are called:

Any disturbance of the structure or function of the body is a pathological condition. This condition is termed a/an:

There are four categories of factors that increase the individual's vulnerability to developing a disease. These categories are genetic, physiological, age and lifestyle. These factors are called:

The technique used in physical examination where the examiner feels the texture, size, consistency and location of certain parts of the body with the hands s

When a disease results in a structural change in an organ that interferes with its functioning, this is a/an:

Listening for bowel sounds is done over all four quadrants of the abdomen using the diaphragm of the stethoscope. The normal rate of bowel sounds per minute is:

Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation: