The nurse is caring for a client with severe inflammation. Which ...

[lindiwe]

The nurse is caring for a client with severe inflammation. Which assessment findings would indicate a systemic reaction to inflammation?
 
  Select all that apply.
  A) Erythema
  B) Edema
  C) Pain
  D) Tachypnea
  E) Tachycardia

Question 2

A school-age client is experiencing photophobia, a sore neck, chills, and fever. During a physical assessment, the nurse uses the technique in the Exhibit. Why did the nurse use this technique when assessing the client?
 
  A) It is a routine part of the physical assessment.
  B) The client's symptoms indicated meningitis
  C) The nurse was assessing range of motion of the neck.
  D) The nurse was assessing optic nerve functioning.

[mistyjohnson]

Answer to Question 1

Answer: D, E

If the nurse observes a systemic reaction, the client will exhibit manifestations including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment indicate a local reaction.

Answer to Question 2

Answer: B

The client's manifestations of a sore neck, chills, fever, and photophobia are consistent with meningitis. Assessing for the Brudzinski sign is not a routine part of the physical assessment. This maneuver is not done to assess for neck range of motion or optic nerve functioning.