What will the nurse most likely assess in the client diagnosed ...

[Wadzanai]

What will the nurse most likely assess in the client diagnosed with a systemic infection?
 
  1. Edema, rubor, heat, and pain
  2. Fever, malaise, anorexia, nausea, and vomiting
  3. Palpitations, irritability, and heat intolerance
  4. Tingling, numbness, and cramping of the extremities

Question 2

What instructions is the most important for the nurse to give a client who is about to be discharged and has a surgical wound?
 
  1. Adjust the diet so it contains more fruits and vegetables.
  2. Apply lubricating lotion to the edges of the wound.
  3. Notify the physician if with any edema, heat, or tenderness at the wound site.
  4. Thoroughly irrigate the wound with hydrogen peroxide.

[soda0602]

Answer to Question 1

Correct Answer: 2
Rationale 1: Edema, rubor, heat, and pain are symptoms of a local infection.
Rationale 2: Fever, malaise, anorexia, nausea, and vomiting are symptoms of a systemic infection.
Rationale 3: Palpitations, irritability, and heat intolerance are symptoms of a thyroid condition.
Rationale 4: Tingling, numbness, and cramping of the extremities would indicate symptoms of hypocalcemia.

Answer to Question 2

Correct Answer: 3
Rationale 1: Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice.
Rationale 2: Applying lubricating lotion to the edges of a wound would impede the healing process.
Rationale 3: A client being discharged with an open surgical wound has to be instructed on the detection of infection since the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection.
Rationale 4: Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing.

[Wadzanai]

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[soda0602]

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