Patho Chap 3

A client has been diagnosed with osteomyelitis and admitted to the hospital. The client's fever persists throughout most of the day but returns to normal at least twice a day. Which pattern of fever is this client displaying?

Intermittent

A client asks the nurse what is the most common objective symptom of systemic inflammation during the acute-phase response. The best response would be:

Fever

Which clients are showing manifestations of infection? Select all that apply.

-A 25-year-old, temperature 40°C (104°F), sweating, shivering, states generalized pain -A 75-year-old, temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue -A 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis

A nurse's hand-off report states that a patient's temperature is 106.6°F. Which of the following may have caused the patient's temperature to elevate past 105.8°F? Select all that apply.

-Convulsions -Hyperthermic state

Subcutaneous fat affects the body's ability to insulate itself because of which of the following? Select all that apply.

-It adds thickness to the body's outer shell -Its poor ability to conduct body heat

In which of the following patients should the nurse anticipate the necessity of regulating body temperature through a heat-gain response? Select all that apply.

-Patient with hyperthyroidism -Patient in a huddle position

A client has presented to the emergency department after he twisted his ankle while playing soccer. Which assessment findings are cardinal signs that the client is experiencing inflammation? Select all that apply.

-The ankle appears to be swollen -The ankle is warmer than the unaffected ankle -The client is experiencing pain -The client's ankle is visibly red

A client has experienced an acute inflammatory response with an elevation of white blood cells. The nurse is reviewing the client's most recent lab results to determine if the counts have returned to a normal range. Select the result that suggests the client is now within normal range.

4000 to 10,000 cells/μL

A nurse is providing care for several clients on a neurological unit of a hospital. With which of the following clients would the nurse be justified in predicting a problem with thermoregulation?

A 66 year old male with damage to his thalamus secondary to a cerebral vascular accident.

Which symptom indicates the next stage of a fever after a prodrome?

A chill

A client presents with an oral temperature of 38.7°C and painful, swollen cervical lymph nodes. Laboratory results indicate neutrophilia with a shift to the left. Which diagnosis is most likely?

A severe bacterial infection

An older adult's dysfunctional temperature regulator function places the client at greatest risk for:

An older adult's dysfunctional temperature regulator function places the client at greatest risk for:

An 88 year old resident of a long term care home has been suffering from a three day onset of increasing shortness of breath and decreased oxygen saturation. At the hospital, an anterior-posterior chest X-ray and sputum culture and sensitivity has confirmed a diagnosis of bacterial pneumonia, yet the client's tympanic temperature has not exceeded 37.3°C (99.2°F). The health care team would recognize that which of the following phenomena likely underlies this situation?

An older adult's hypothalamus has diminished thermoregulatory ability.

Which of the following is an appropriate action by a nurse to take in attempting to decrease a patient's temperature through conduction?

Apply cooling blanket

The loss of heat from the body through the circulation of air currents is known as which of the following?

Convection

The nurse is assessing a client for acute inflammation of a wound. For which of these symptoms of infection does the nurse assess?

Edema

The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as:

Exudate containing white blood cells, protein, and tissue debris

The nurse is assessing a client who is in the prodromal stage of a fever. The nurse anticipates the client will exhibit:

Fatigue

The nurse is caring for a client whose temperature is increasing. The nurse is aware that the client will also experience an increase in:

Heart rate

When explaining the final stages of the inflammatory response to pathogens, the nurse will educate the patient about:

How the body can kill the pathogen by generating toxic oxygen and nitrogen products producing such things as nitric oxide and hydrogen peroxide.

What is the most common cause of drug fever?

Hypersensitivity reaction to medication

A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as an:

Increase in circulating neutrophils

The nurse evaluating the bloodwork results of a client with an infected leg ulcer. The white blood cell count is 18,000 cells/uL. The nures inteprets this as:

Leukocytosis

A two-day postoperative patient's temperature was 98.5°F at 3:00 pm. At 6:00 pm, the unlicensed assistant notifies the nurse that the patient's temperature is 102.0°F. Which of the following actions should the nurse take?

Notify the physican

A patient has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for the patient with which of the following types of fever?

Neurogenic

A patient presented to the emergency department of the hospital with a swollen, reddened, painful leg wound and has been diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) cellulitis. The patient's physician has ordered a complete blood count and white cell differential. Which of the following blood components would the physician most likely anticipate to be elevated?

Neutrophils

A client is said to be in the chill stage of the fever process when the nurse does which of the following?

Observes piloerection on the skin

Which of the following patients is most likely to have impairments to the wound healing process? A patient with:

Poorly controlled blood sugars with small blood vessel disease.

Place the four successive stages of fever in correct order.

Prodromal Chill Flush Defervescence

A patient has a mild headache and fatigue. He also states he has some aches and pains. Which of the following stages of fever does the nurse determine the patient is experiencing?

Prodrome

The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading?

Rectal

The route considered the most accurate to measure a core body temperature is which of the following?

Rectal

A client in the acute stage of inflammation will experience vasodilation of the arterioles and congestion in the capillary beds. The nurse would assess the client's skin for:

Redness

A patient is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for which of the following?

Temperature

A nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for:

Rubor, swelling, and pain

A client has developed systemic inflammatory response syndrome. The nurse is aware that this results from:

Severe bacterial infections (sepsis)

A client with pneumonia is admitted with these vital signs: temperature 99.7ºF, pulse 80 beats/min, respirations 18/minute, and BP 120/80 mmHg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later?

T 100.9ºF, P 90/min, R 20/min, BP 126/80 mmHg

The nurse assessing a client admitted with a diagnosis of "fever of unknown origin" notes that the temperature is elevated, but the heart rate is within normal range. What further assessment will the client require?

Test for Legionnaire disease

A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the patient's temperature on admission and finds that it is 96.6°F. Which of the following describes how the nurse should interpret the finding?

The patien tmay be exhibiting a blunted or absent febrile response.

A 33-year-old client is brought into the emergency room with a core temperature of 39°C (102.2°F). The client is red in the face, chest, and back due to significant cutaneous vasodilation. The client is likely in which stage of fever?

Third