While performing an assessment on a client with alterations in tissue integrity, which of the following cues should a nurse recognize as indicative of possible infection?
Dry and itchy skin.
Increased pigmentation.
Warmth and redness at the site.
Presence of hair follicles.
The Correct Answer is C
Choice A rationale
Dry and itchy skin, or pruritus, is often associated with healing or chronic conditions like eczema and xerosis. While uncomfortable, it is not a primary indicator of an acute infectious process. Itching often results from the release of histamine during the inflammatory phase of wound healing or from a lack of sebaceous gland activity in damaged tissue. It does not typically signify the presence of pathogenic microorganisms requiring antibiotic therapy, though it can lead to secondary infections if the client scratches.
Choice B rationale
Increased pigmentation, or hyperpigmentation, usually occurs as a result of post inflammatory changes or chronic sun exposure. It is a sign of melanocyte activity in response to skin injury or inflammation but does not indicate an active infection. In some cases, it can be a normal part of the scarring process. Infection is more commonly associated with changes in color toward bright red or purple rather than a darkening of the skin's natural melanin or pigment.
Choice C rationale
Warmth and redness, also known as calor and rubor, are two of the classic cardinal signs of inflammation and infection. Increased blood flow to the site of injury occurs as the body delivers white blood cells to combat pathogens. If these signs spread beyond the immediate borders of a wound, it suggests cellulitis or a localized infectious process. This physiological response is triggered by chemical mediators like prostaglandins and kinins, which increase vascular permeability and vasodilation at the site.
Choice D rationale
The presence of hair follicles is a normal anatomical finding and generally indicates that the dermal layer is intact or regenerating effectively. Hair follicles are not associated with the pathology of infection. In fact, deep full thickness burns often destroy hair follicles, so their presence might actually suggest a more superficial injury. Their existence has no diagnostic value in determining whether a wound has been colonized or infected by bacteria, viruses, or fungi during the healing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Hydration is critical for maintaining the structural integrity and turgor of the skin cells. Adequate fluid intake supports the delivery of essential nutrients to the dermis and facilitates the removal of metabolic waste products. Dehydrated skin is more prone to cracking, which compromises the primary barrier against pathogens. Nurses must emphasize that water intake helps maintain the acid mantle and promotes faster cellular regeneration in areas where tissue integrity has been previously altered.
Choice B rationale
Altered tissue integrity creates a portal of entry for opportunistic microorganisms, significantly increasing the risk of localized or systemic infection. Nurses must monitor for clinical signs such as erythema, warmth, edema, purulent drainage, and localized pain. The normal white blood cell count range is 5,000 to 10,000 cells per microliter; elevations may indicate an escalating inflammatory response. Early detection of these cues allows for prompt antimicrobial intervention and prevents complications like sepsis.
Choice C rationale
Prolonged sun exposure is contraindicated for patients with altered tissue integrity because ultraviolet radiation induces DNA damage and further weakens the epidermal barrier. UV rays can cause thermal injury to already compromised areas and exacerbate inflammation. This can lead to delayed wound healing and increase the risk of malignant transformations like melanoma or basal cell carcinoma. Protecting the skin from excessive solar radiation is a fundamental nursing action to promote healing and prevent further damage.
Choice D rationale
Ignoring changes in skin color or temperature is a failure in nursing assessment that can lead to missing signs of ischemia or infection. Changes in color, such as pallor or cyanosis, often indicate poor perfusion, while increased temperature typically signals inflammation or infection. These assessment findings are vital indicators of the success or failure of current interventions. A diligent nurse must document and report these shifts immediately to adjust the plan of care appropriately.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Tachycardia in the burn patient frequently signals a deficit in circulating blood volume. When the vascular space loses fluid due to increased capillary permeability, the stroke volume decreases significantly. To compensate and maintain an adequate cardiac output, the sinoatrial node increases the firing rate. While pain or stress can raise the heart rate, a sustained increase in the absence of adequate fluid resuscitation is a classic indicator of systemic dehydration or hypovolemic shock.
Renal perfusion is highly sensitive to changes in mean arterial pressure and total intravascular volume. In a state of dehydration or inadequate fluid resuscitation after a burn, the kidneys conserve water by activating the renin-angiotensin-aldosterone system. This results in a marked decrease in urine output, often falling below the standard minimum of 0.5 mL per kg per hour. Low output reflects a physiological attempt to maintain blood pressure despite the massive fluid shifts and losses.
Blood Urea Nitrogen measures the concentration of nitrogenous waste in the blood. In dehydration, the kidneys reabsorb more water, which leads to a higher concentration of urea in the plasma. Normal BUN levels typically range from 7 to 20 mg/dL. When the patient is dehydrated, this value rises because there is less solvent available to dilute the solute. This elevation is a primary biochemical marker used to assess the severity of fluid volume deficits.
Hematocrit measures the percentage of red blood cells relative to total blood volume. In fluid overload, the intravascular space is expanded with excess plasma or intravenous fluids, which dilutes the cellular components of the blood. This hemodilution causes the hematocrit percentage to drop below the normal range, which is approximately 42 to 52 percent for men and 37 to 47 percent for women. This finding helps distinguish excessive fluid administration from the hemoconcentration seen in early burns.
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