Author Question: During assessment of a client's infection site, the nurse determines that the site is warm to the ... (Read 80 times)

plus1 · **on:** Jul 23, 2018

During assessment of a client's infection site, the nurse determines that the site is warm to the touch. How should the nurse explain this warmth to the client?

1. Infection causes fluid overload in your body, so the infected site gets warm and red.
2. Your lymphatic system has shut down to keep the infection from spreading, so the site gets warm and red.
3. The little vessels around your infection are leaking, so the area gets warm and red.
4. Your body is sending extra blood and white cells to the site to fight the infection.

Question 2

A client asks, Why does the infection in my finger make it so red? What is the nurse's best response?

1. When you have an infection, your body sends more blood to the area.
2. Your blood vessels in that area are leaky.
3. You don't get rid of fluid as quickly when you are sick, so you develop a fluid overload.
4. Your fingers are small and a long way from your heart, so the lymph drainage is not as good.

kthug · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 4
Rationale 1: Fluid overload does not cause erythema.
Rationale 2: Blocked lymphatic drainage does not cause erythema.
Rationale 3: Increased capillary permeability does not cause erythema.
Rationale 4: Increased blood flow causes warmth and redness.
Global Rationale: The central purposes of inflammation are to contain the injury, destroy the pathogen, and initiate repair of the area. The repair of the injured area can proceed at a faster pace by neutralizing the foreign agent and removing cellular debris and dead cells. Signs of inflammation include swelling, pain, warmth, and redness of the affected area. Histamine dilates nearby blood vessels, resulting in increased blood flow to the area, sometimes congesting the area with blood. This often results in the area feeling warmer than surrounding tissues.
Fluid overload does not cause this response, nor does blocked lymphatic drainage or decreased capillary permeability.

Answer to Question 2

Correct Answer: 1
Rationale 1: Erythema is caused by increased blood flow to the area.
Rationale 2: Increased capillary permeability does not cause erythema.
Rationale 3: Fluid overload does not cause erythema.
Rationale 4: Blocked lymphatic drainage does not cause erythema.
Global Rationale: The central purposes of inflammation are to contain the injury, destroy the pathogen, and initiate repair of the area. The repair of the injured area can proceed at a faster pace by neutralizing the foreign agent and removing cellular debris and dead cells. Signs of inflammation include swelling, pain, warmth, and redness of the affected area. Histamine dilates nearby blood vessels resulting in increased blood flow to the area, sometime congesting the area with blood. This often results in redness of the area. Leaky blood vessels are associated with swelling. The patient is not fluid overloaded nor is the distance from the heart a major factor in this response.