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What is not an expected assessment finding in a client with inflammation? (Select all that apply.)

Polyuria

Edema

Heat

Erythema

Pain

Answer and Explanation

Correct Answer : A,B

Choice A reason: Polyuria is the production of abnormally large amounts of urine, which can be caused by various factors, such as diabetes, kidney disease, or diuretics. Polyuria is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not affect the urinary system directly, unless the inflammation is located in the kidneys or bladder.

Choice B reason: Edema is the swelling of tissues due to excess fluid accumulation, which can be caused by various factors, such as heart failure, liver disease, or venous insufficiency. Edema is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not cause fluid retention, but rather fluid leakage from the blood vessels into the interstitial spaces.

Choice C reason: Heat is an expected finding in a client with inflammation, which is the body's response to injury or infection. Heat is caused by the increased blood flow to the inflamed area, which brings more oxygen and nutrients to the damaged tissues. Heat also helps to kill or inhibit the growth of microorganisms that may cause infection.

Choice D reason: Erythema is an expected finding in a client with inflammation, which is the body's response to injury or infection. Erythema is the redness of the skin due to the dilation of the blood vessels in the inflamed area, which increases the blood flow and the delivery of oxygen and nutrients to the damaged tissues. Erythema also helps to signal the presence of inflammation and attract immune cells to the site.

Choice E reason: Pain is an expected finding in a client with inflammation, which is the body's response to injury or infection. Pain is caused by the stimulation of the nerve endings by chemical mediators, such as histamine, prostaglandins, and bradykinin, that are released by the inflamed tissues. Pain also helps to alert the client of the injury or infection and to limit the movement or use of the affected area.

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Correct Answer is A

Explanation

Choice A reason: Blanching is the term that the nurse documents for this finding, because it describes the temporary whitening of the skin when pressure is applied. Blanching indicates that the blood vessels in the skin are constricted or compressed, and that the blood flow is reduced or interrupted. Blanching can be a normal response to cold, stress, or pressure, or it can be a sign of a problem, such as ischemia, infection, or inflammation.

Choice B reason: Warmth is not the term that the nurse documents for this finding, because it describes the increased temperature of the skin, not the color change. Warmth indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced. Warmth can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.

Choice C reason: Redness is not the term that the nurse documents for this finding, because it describes the original color of the skin, not the color change. Redness indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced, as explained above. Redness can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.

Choice D reason: Nonblanching is not the term that the nurse documents for this finding, because it describes the opposite of what the nurse observed. Nonblanching means that the skin does not turn white when pressure is applied, but rather remains red or purple. Nonblanching indicates that the blood vessels in the skin are damaged or ruptured, and that the blood has leaked into the surrounding tissues. Nonblanching can be a sign of a serious problem, such as bruising, bleeding, or necrosis.

A. Increased agitation B. Decreased attention span C. Grimacing D. Reported pain of 5/10 E. Increase in heart rate

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Increased agitation is a nonverbal sign of pain, because it indicates that the client is restless, uncomfortable, or distressed by the pain. Agitation can manifest as fidgeting, tossing, turning, moaning, or groaning.

Choice B reason: Decreased attention span is not a nonverbal sign of pain, but rather a cognitive or behavioral sign of pain. Decreased attention span means that the client has difficulty focusing, concentrating, or remembering things, which can be affected by pain. However, decreased attention span is not a direct expression of pain, but rather a consequence of pain.

Choice C reason: Grimacing is a nonverbal sign of pain, because it indicates that the client is experiencing facial muscle tension, contraction, or distortion due to the pain. Grimacing can manifest as frowning, wrinkling the forehead, pursing the lips, or clenching the teeth.

Choice D reason: Reported pain of 5/10 is not a nonverbal sign of pain, but rather a verbal sign of pain. Reported pain of 5/10 means that the client has communicated the intensity of their pain using a numerical scale, which is a subjective and selfreported measure of pain. However, reported pain of 5/10 is not a direct expression of pain, but rather a description of pain.

Choice E reason: Increase in heart rate is a nonverbal sign of pain, because it indicates that the client is experiencing physiological changes due to the pain. Increase in heart rate can manifest as tachycardia, palpitations, or arrhythmias.

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This is the edited text:What is not an expected assessment finding in a client with inflammation? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What term does the nurse document for this finding?

Correct Answer is A

Explanation

Which assessment is a nonverbal sign of pain? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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This is the edited text:

What is not an expected assessment finding in a client with inflammation? (Select all that apply.)