The nurse recognizes that a patient has an inflammatory response ...

[fnuegbu]

The nurse recognizes that a patient has an inflammatory response in a surgical wound on the leg when:
 
  a. a foul drainage is coming from the wound.
  b. the affected leg is cooler than the other leg.
  c. there are raised, red, pruritic welts on the leg.
  d. rubor and edema appear around the wound.

Question 2

An example of an appropriate nursing diagnosis is:
 
  a. impaired skin integrity.
  b. skin breakdown noted.
  c. turn patient every 2 hours.
  d. the patient has scabies on his back.

[xiaomengxian]

Answer to Question 1

D
Rubor and edema are two of the cardinal signs of an inflammatory response. Foul drainage suggests infection, the affected leg being cooler than the other leg suggests circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy.

Answer to Question 2

A
Impaired skin integrity is an example of a nursing diagnosis. Skin breakdown noted is an example of a charting entry, turn patient every 2 hours is a nursing intervention, and scabies is a medical diagnosis.