A nurse is assessing a client who was brought to the emergency department with a new ankle injury. Which manifestation should the nurse expect as a result of localized inflammation?

A. Sanguineous drainage represents active bleeding or fresh bloody discharge from an open wound or incision. While it may accompany an injury, it is not one of the five cardinal signs of the localized inflammatory response. Inflammation can occur in closed tissue injuries, such as a sprain, where no external drainage is present but internal cellular changes are occurring. B. Increased warmth, or calor, is a cardinal sign of inflammation caused by localized vasodilation and increased blood flow to the injured area. Chemical mediators like histamine and bradykinin cause the capillaries to widen, bringing warmer core blood to the surface of the affected tissue. This physiological response is intended to deliver leukocytes and nutrients necessary for the tissue repair process. C. Palpable pedal pulses indicate adequate arterial perfusion to the distal extremity but are not a result of the inflammatory process itself. In cases of severe localized inflammation and edema, pressure on the vasculature can actually diminish the strength of distal pulses. While the nurse should assess for pulses, their presence is a sign of normal circulatory function rather than an inflammatory manifestation. D. A full range of motion is typically lost during localized inflammation due to pain and swelling (tumor) within the joint or surrounding soft tissue. Edema increases interstitial pressure, which mechanically restricts movement, while inflammatory mediators sensitize nociceptors to produce pain during activity. Expecting a full range of motion in a newly injured, inflamed ankle is clinically inconsistent with inflammatory pathophysiology.