The nurse is caring for a client with inflammation and is doing ...

[Tirant22]

The nurse is caring for a client with inflammation and is doing the morning assessment. Which of the following manifestations indicate a systemic reaction associated with an inflammatory response?
 
  1. Erythema
   2. Pain
   3. Tachypnea
   4. Edema

Question 2

The nurse is planning care for the client who has been admitted with metabolic alkalosis. Which of the following is a priority nursing diagnosis for this client?
 
  1. Fluid Volume Excess
   2. Risk for Impaired Gas Exchange
   3. Risk for Hypothermia
   4. Ineffective Health Maintenance

[fwbard]

Answer to Question 1

3. Tachypnea

Rationale:
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

2. Risk for Impaired Gas Exchange

Rationale:
Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and reduction of the depth of respirations leading to the retention of carbon dioxide. Clients with metabolic alkalosis often have an accompanying fluid volume deficit. With the fluid volume deficit, the client would experience hyperthermia. Ineffective health maintenance would not be a priority during the acute phase of the disease but, rather, a teaching opportunity before discharge depending on the cause of the metabolic alkalosis.