Answer to Question 1
D
A sign of an acute inflammatory process is pain. The swelling of inflamed tissues increases pressure on nerve endings, causing pain. Chemical substances such as histamine also stimulate nerve endings, adding to the pain response.
The skin is not blanched, but rather with the increase in local blood flow, it is reddened.
The symptom of localized warmth results from a greater volume of blood at the inflammatory site.
The cellular response of acute inflammation involves WBCs arriving at the site, creating an in-crease in WBCs, not a decrease.
Answer to Question 2
B
Positioning the client upright is an independent nursing intervention for the promotion of respir-atory function in a terminally ill client.
Limiting fluids may not promote respiratory function, and the nurse should not do so unless a client is on a fluid-restricted diet.
Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. A respiratory rate should be assessed before administering narcotics to prevent further respiratory depression. Management of dyspnea (air hunger) involves judicious administration of morphine and anxiolytics for relief of respiratory distress.
The administration of bronchodilators would require a physician's order. It is not an independent nursing activity.
Intervention Model-Response to Client Misconduct
Sample client goals from the Wellness Massage Pyramid.
Basic sliding effleurage using the forearm applies broad, deep pressure to an area.
Measuring the client’s weight with a standard platform scale
Positioning the client