EDAPT: Altered Inflammation and Immunity

A young adult asks the nurse about options for removing several keloid scars on their neck and ear. Which statement made by the nurse is most accurate?

"The keloid scarring can be removed, but it may come back."

Which statement best describes negative pressure wound therapy (NPWT)?

A vacuum source that promotes removal of fluid, exudate, and infectious debris for healing and closure

A guest at a wedding reception twisted their ankle and fell while dancing. The guest's friend takes them to an urgent care center to be evaluated. Which two items should the nurse evaluate first? Select that all apply.

Capillary refill Distal pulses​

The nurse is caring for a client who has been admitted with an acute asthma exacerbation secondary to an allergic reaction. Albuterol is administered to open the airway. Which medication does the nurse anticipate administering to reduce inflammation?

Corticosteroid

As the human immunodeficiency virus (HIV) progresses, the CD4 cell count __________. The lower the viral load, the __________active the disease. A CD4 cell count below __________/microliter means the client has progressed to AIDS.

Decreases Less 200

Which factors play a role in delaying wound healing? Select all that apply.

Diabetes mellitus Obesity Smoking

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who states, "I feel that there is no hope or reason to live." Which response by the nurse is most appropriate?

"Can you tell me more about how you are feeling?"

The nurse caring for a client with an infected wound asks an unlicensed assistive personnel (UAP) to assist with the next dressing change. Which statement made by the UAP should be addressed by the nurse immediately?

"How do you deal with that gross smell?"

Which documented description is best for this wound?

"Oval-shaped wound bed that is pink and moist, approximately 6 cm x 4 cm with undermining noted at the 12 o'clock to 1 o'clock position."

A client asks what effect nutrition has on skin integrity. Which response provided by the nurse is most accurate?​

"Poor dietary intake of​ kilocalories, protein, and iron can increase the risk of pressure​ injuries."

A guest at a wedding reception twisted their ankle and fell while dancing. What should be done to provide first aid? Select all that apply.

Wrap the ankle with a compression bandage. Elevate the ankle. Ask the guest if they have pain anywhere else.

Select the cues that indicate the client is having an allergic reaction. Susie Goodman (pronouns: she/her/hers), age 42, presents to the emergency department (ED) with a rash over most of the body, urticaria, pruritis, tearing, sniffling, severe headache, and constant throat clearing. She has a history of food allergies but denies exposure to allergens. Her daughter recently adopted a cat. ​ Susie takes amlodipine for hypertension and glyburide for diabetes mellitus type 2.

Rash Pruritis Sniffling Constant throat clearing

The nurse is caring for a client with diabetes mellitus type 1 who is 72 hours postoperative surgical removal of the descending colon and rectum with the placement of a transverse colostomy. During the assessment, the client has a temperature of 102.6 °F (39.2 °C) and increasing amounts of purulent, serosanguineous drainage from the abdominal incision. The client reports pain of 10/10 to the abdominal incision. Which statements indicate the client understands how to care for themselves after discharge? Select all that apply.

"The inflammation around the incision may be present after I complete the antibiotics." "I should not decrease the amount of protein I eat."

For each clinical manifestation, identify if the symptom represents an acute infection, a chronic infection, or acquired immunodeficiency syndrome (AIDS).

*Acute Infection:* Swollen lymph nodes Sore throat *Chronic Infection:* Frequent night sweats Candida infections Chronic diarrhea *AIDS:* CD4 cell count below 200 Wasting syndrome

The nurse is caring for a client who is admitted with dehydration secondary to malnutrition and wasting syndrome. The client is diagnosed with human immunodeficiency virus (HIV). Vital signs are T 97 °F (36.1 °C), BP 90/50, HR 105, RR 28, and oxygen saturation 89% on room air. The client is taking a prescribed antiretroviral therapy regimen. However, the laboratory findings show WBC 3000, hematocrit 37%, CD4 350/microliter, and a significantly elevated viral load. For each nursing action, identify if the action is essential, non-essential, or contraindicated at this time.

*Essential:* • Administer 0.9% sodium chloride bolus. • Administer supplemental oxygen 2 liters via nasal cannula. *Non-Essential:* • Implement contact precautions. *Contraindicated:* • Discontinue antiretroviral therapy regimen until acute problems are resolved.

Susie Goodman (pronouns: she/her/hers), age 42, presents to the emergency department (ED) with a rash over most of the body, urticaria, pruritis, tearing, sniffling, severe headache, and constant throat clearing. She has a history of food allergies but denies exposure to allergens. Her daughter recently adopted a cat. ​ Susie takes amlodipine for hypertension and glyburide for diabetes mellitus type 2. For each potential prescription, indicate if the prescription is essential, nonessential, or contraindicated.

*Essential:* • Diphenhydramine 50 mg by mouth now. • Cromolyn 200 mg four times daily by mouth. • Remove the cat from the home. *Nonessential:* • Decrease glyburide from 5 mg daily to 2.5 mg daily by mouth. *Contraindicated:* • Immunotherapy to treat food allergies.

For each body fluid, select whether the fluid can or cannot transmit human immunodeficiency virus (HIV).

*HIV can be transmitted through:* Blood Breast milk Vaginal fluid Semen *HIV cannot be transmitted through:* Tears Sputum Sweat Urine

The nurse is caring for a client who is admitted with dehydration secondary to malnutrition and wasting syndrome. The client is diagnosed with human immunodeficiency virus (HIV). Vital signs are T 97 °F (36.1 °C), BP 90/50, HR 105, RR 28, and oxygen saturation 89% on room air. The client is taking a prescribed antiretroviral therapy regimen. However, the laboratory findings show WBC 3000, hematocrit 37%, CD4 350/microliter, and a significantly elevated viral load. For each assessment finding, indicate if the client's condition has improved, declined, or is unchanged.

*Improved:* Blood pressure 110/72 Oxygen saturation 92% Decreased viral load *Declined:* Temperature 101.4 °F (38.6 °C) *Unchanged:* CD4 count 350/microliter

The nurse is caring for a client with diabetes mellitus type 1 who is 72 hours postoperative surgical removal of the descending colon and rectum with the placement of a transverse colostomy. During the assessment, the client has a temperature of 102.6 °F (39.2 °C) and increasing amounts of purulent, serosanguineous drainage from the abdominal incision. The client reports pain of 10/10 to the abdominal incision. The nurse is planning education for the client with diabetes mellitus type 1 who is being discharged home with a large abdominal wound. For each dietary recommendation below, specify if the recommendation should or should not be included in the teaching plan.

*Included:* • Increasing intake of green, leafy vegetables. • Adding citrus fruits and tomatoes. • Drinking more water. *Not Included:* • Limiting protein intake • Decreasing dairy intake. • Eating more carbohydrates.

The nurse is caring for a client with diabetes mellitus type 1 who is 72 hours postoperative surgical removal of the descending colon and rectum with the placement of a transverse colostomy. During the assessment, the client has a temperature of 102.6 °F (39.2 °C) and increasing amounts of purulent, serosanguineous drainage from the abdominal incision. The client reports pain of 10/10 to the abdominal incision. For each potential healthcare provider prescription, specify if the intervention is anticipated, nonessential, or contraindicated for the care of this client.

*Indicated:* • Obtain a culture and sensitivity of the drainage. • Administer acetaminophen. *Nonessential:* • Provide a tepid water bath. • Decrease the temperature of the client's room to 68 °F (20 °C). *Contraindicated:* • Place the client on contact isolation.

The nurse is completing a skin assessment on Jan (pronouns: she, her), who lives in a nursing care facility after a stroke left her unable to care for herself. Jan developed a pressure ulcer on her coccyx after being in bed for a week with influenza. For each potential nursing action, click to specify if the intervention is indicated, nonessential, or contraindicated when caring for Jan.​

*Indicated​:* • Applying a moisture barrier to the perianal area​. • Turning the client at least every 2 hours​. • Encouraging oral fluid intake​. *Nonessential​:* • Changing bed linens six times per day​. *Contraindicated​:* • Massaging the reddened skin​. • Restricting caloric intake to 800 Kcal per day​.

The nurse is caring for a client with diabetes mellitus type 1 who is 72 hours postoperative surgical removal of the descending colon and rectum with the placement of a transverse colostomy. During the assessment, the client has a temperature of 102.6 °F (39.2 °C) and increasing amounts of purulent, serosanguineous drainage from the abdominal incision. The client reports pain of 10/10 to the abdominal incision. For each assessment finding, select if the finding indicates infection, inflammation, or both.

*Infection:* • Redness around incision • Skin around incision warm to touch • Incisional pain 10/10 • Fever 102.6 °F (39.2 °C) • Swelling around incision *Inflammation:* • Redness around incision • Skin around incision warm to touch • Incisional pain 10/10 • Swelling around incision

For each prevention measure, indicate if the strategy is used to prevent transmission via sexual activities, drug injection, workplace exposure, or perinatal transmission.

*Sexual Activities:* Practice abstinence. Use a female condom. *Drug Injection:* Avoid sharing needles. *Workplace Exposure:* Use needle safety devices appropriately. Use standard precautions. *Perinatal Transmission:* Seek early prenatal care. Do not breastfeed.

Demonstrate knowledge of the pathophysiology of human immunodeficiency virus (HIV) by placing the statements in the correct order.

1. HIV enters the CD4 cell by binding to protein receptors. 2. Single-stranded HIV DNA becomes double-stranded viral DNA. 3. Double-stranded HIV DNA integrates itself into the genetic structure. 4. The CD4 cell is destroyed.

The nurse is caring for a client who is admitted with dehydration secondary to malnutrition and wasting syndrome. The client is diagnosed with human immunodeficiency virus (HIV). Vital signs are T 97 °F (36.1 °C), BP 90/50, HR 105, RR 28, and oxygen saturation 89% on room air. ​ The client is taking a prescribed antiretroviral therapy regimen. However, the laboratory findings show WBC 3000, hematocrit 37%, CD4 350/microliter, and a significantly elevated viral load. Based on the assessment findings, place the nursing diagnosis in the correct priority order.

1. Impaired gas exchange 2. Deficient fluid volume 3. Imbalanced nutrition: less than body requirements 4. Deficient knowledge

Which clients are at high risk for developing dehiscence of a postoperative abdominal incision? Select all that apply.

A middle-aged adult with a body mass index (BMI) of 38.2 An older adult with postoperative sepsis. A young adult with diabetes mellitus type 1 (DM1).

Which is the best example of active acquired immunity?

Administration of an intramuscular influenza vaccine.

Which is the best example of artificial passive acquired immunity?

Administration of intravenous gamma globulin.

Which client would benefit the most from a moist-to-dry dressing (mechanical debridement)?

An adolescent who has necrotic tissue present in the wound bed.

Which risk factors predispose a client to developing a serious allergic reaction? Select all that apply.

Angioedema after eating peanut butter Diagnosed with asthma at age 14 Facial swelling after strawberries

How will the nurse best assess the client for a suspected deep tissue injury if they have darker skin tones?

Assess the area for changes in temperature or consistency.

​Jan (pronouns: she, her) was admitted to the hospital from a residential care facility. Her history includes a stroke with residual musculoskeletal and neurological deficits on her right side. Which nursing action would be most helpful in preventing Jan from developing a pressure ulcer?​

Assist Jan to reposition every 2 hours.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is admitted for malnutrition. The client's CD4 cell count is less than 200/microliter, so neutropenic precautions must be implemented. Which actions by the nurse will protect the client from infection? Select all that apply.

Avoid raw, unwashed fruits on the client's meal tray. Prohibit dried or fresh flowers in the client's room. Place the client in a single-occupancy room. Closely monitor for signs and symptoms of infection.

What are common locations for pressure ulcers or sores? Select all that apply.

Back of the head Coccyx Ears Elbows Heels

The nurse is caring for a client who has an anaphylactic reaction following the administration of penicillin. Which medication does the nurse anticipate administering first?

Epinephrine

Select the correct description for each type of transplant rejection.

Hyperacute Rejection - A client who is six hours postoperative from a liver transplant is experiencing signs of rejection. Acute Rejection - A client who had a heart transplant four months ago is experiencing his third rejection episode. Chronic Rejection - A client who had a pancreas transplant three years ago has developed scaring and fibrosis due to rejection episodes.

Susie Goodman (pronouns: she/her/hers), age 42, presents to the emergency department (ED) with a rash over most of the body, urticaria, pruritis, tearing, sniffling, severe headache, and constant throat clearing. She has a history of food allergies but denies exposure to allergens. Her daughter recently adopted a cat. ​ Susie takes amlodipine for hypertension and glyburide for diabetes mellitus type 2. The client has clinical manifestations of an allergic reaction, which is a __________ response involving __________ immunoglobulins. This type of immune response results in an inflammatory response __________ the creation of T and B cells.

Hypersensitivity IgE Without

Which medications may be used to treat human immunodeficiency virus (HIV)? Select all that apply.

Ibalizumab Maraviroc Tenofovir Atazanavir

Which class of immunoglobins increases during an allergic reaction?

IgE

Which are common risk factors associated with pressure ulcer development? Select all that apply.

Increased temperature​ Incontinence Obesity

Adam (pronouns: he/him/his) is a 22-year-old student who loves to skateboard and spend time outside. Recently, while skateboarding, Adam fell and broke his wrist. After surgery to repair his wrist, Adam's incision was sutured closed. The nurse is assessing Adam's incision from his wrist surgery. Observe the wound in the image shown here. Which descriptive words would be appropriate to include in the nurse's assessment note? Select all that apply.

Inflamed Purulent​ Red​

Which statement regarding infection and inflammation is correct?

Inflammation is always present with infection.

When reviewing the immunization needs of a client with human immunodeficiency virus (HIV) and a CD4 count of less than 200 mm3, which vaccines should be avoided?

Live attenuated vaccines

Susie Goodman (pronouns: she/her/hers), age 42, presents to the emergency department (ED) with a rash over most of the body, urticaria, pruritis, tearing, sniffling, severe headache, and constant throat clearing. She has a history of food allergies but denies exposure to allergens. Her daughter recently adopted a cat. ​ Susie takes amlodipine for hypertension and glyburide for diabetes mellitus type 2. After administration of diphenhydramine, which symptoms should the nurse anticipate will resolve? Select all that apply.

Nasal stuffiness Pruritis Urticaria

A nurse is caring for a client who was sexually assaulted and is concerned about exposure to the human immunodeficiency virus. The healthcare provider prescribes post-exposure prophylaxis (PEP). What information should the nurse provide to the client about this medication? Select all that apply.

PEP must be taken for 28 days after exposure. Raltegravir will be taken twice daily, and Truvada will be taken daily.

​Which description is discussing a Stage II pressure ulcer?

Partial thickness loss of dermis, shallow open ulcer with a red-pink wound bed without slough.

Susie Goodman (pronouns: she/her/hers), age 42, presents to the emergency department (ED) with a rash over most of the body, urticaria, pruritis, tearing, sniffling, severe headache, and constant throat clearing. She has a history of food allergies but denies exposure to allergens. Her daughter recently adopted a cat. ​ Susie takes amlodipine for hypertension and glyburide for diabetes mellitus type 2. The nurse analyzes the assessment findings and determines which is the most likely cause of the allergic reaction?

Pet allergies

The nurse is completing a skin assessment on Jan (pronouns: she, her), who lives in a nursing care facility after a stroke left her unable to care for herself. Jan developed a pressure ulcer on her coccyx after being in bed for a week with influenza. Jan is at the highest risk of developing __________ and __________.

Pneumonia Sepsis

Adam (pronouns: he/him/his) is a 22-year-old student who loves to skateboard and spend time outside. Recently, while skateboarding, Adam fell and broke his wrist. After surgery to repair his wrist, Adam's incision was sutured closed. This is an example of which process of healing?

Primary intention

The nurse is completing a skin assessment on Jan (pronouns: she, her), who lives in a nursing care facility after a stroke left her unable to care for herself. Jan developed a pressure ulcer on her coccyx after being in bed for a week with influenza. ​ Which statements made by Jan's daughter indicate an understanding of the steps to take to reduce the risk of future pressure ulcers? Select all that apply​.

Request a pressure relieving mattress. Reposition Jan while in bed frequently and get her up to the chair. Assist Jan to the bathroom every 2 hours instead of utilizing adult briefs.

Match each diagnostic test used to detect altered immune response to its corresponding purpose.

Rheumatoid factor, serum - This test is used to diagnose rheumatoid arthritis. Antinuclear antibodies (ANA), serum - This test is used to evaluate the client's system autoimmune disease, particularly systemic lupus erythematosus. Skin testing - This test is used to identify the specific allergens that are causing allergy symptoms. IgD, serum - This test provides information about humoral immune status. C-reactive protein, serum - This test is used to detect systemic inflammatory processes.

Susie Goodman (pronouns: she/her/hers), age 42, presents to the emergency department (ED) with a rash over most of the body, urticaria, pruritis, tearing, sniffling, severe headache, and constant throat clearing. She has a history of food allergies but denies exposure to allergens. Her daughter recently adopted a cat. ​ Susie takes amlodipine for hypertension and glyburide for diabetes mellitus type 2. The nurse is providing education about skin testing, which the healthcare provider has recommended. What information should the nurse provide? Select all that apply.

Saline is applied to the control site. Allergen extracts are applied to the skin in rows. Skin testing typically involves a scratch or prick test on the arms and back.

The nurse is completing a skin assessment on Jan (pronouns: she, her), who lives in a nursing care facility after a stroke left her unable to care for herself. Jan developed a pressure ulcer on her coccyx after being in bed for a week with influenza. ​ Jan responds to verbal commands but cannot always say that she is uncomfortable or that she needs to be repositioned. The nurse notices that Jan never eats a complete meal and rarely finishes more than half of her food tray at mealtimes. While she can make slight adjustments to her position occasionally, Jan requires moderate assistance when moving and frequently slides down in the bed or chair. She cannot bear weight to stand or ambulate. Jan's bed linens are changed at least once a shift due to increased sweating and perspiration. ​ Based on this information, complete the form to calculate Jan's Braden Scale score. ​

Sensory perception - 3 Moisture - 2 Activity - 2 Mobility - 2 Nutrition - 1 Friction and shear - 1

Most adults are infected with human immunodeficiency virus (HIV) through __________ and __________. The most common way that children acquire HIV is through __________.

Sexual intercourse Sharing drug injection equipment Perinatal transmission

Match each ulcer stage to the correct description. Click a stage in the left column and then click the matching description in the right column.

Stage I - Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Stage II - Partial-thickness loss of dermis, shallow open ulcer with a red-pink wound bed without slough. Stage III - Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. Stage IV - Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Exposed bone or muscle is visible or directly palpable.

When caring for a client infected with human immunodeficiency virus (HIV), which transmission-based precautions should be implemented?

Standard precautions

The nurse is completing a skin assessment on Jan (pronouns: she, her), who lives in a nursing care facility after a stroke left her unable to care for herself. Jan developed a pressure ulcer on her coccyx after being in bed for a week with influenza. The nurse is preparing to change Jan's wound dressing. Which items should the nurse collect for use? Select all that apply.​

Sterile gloves and pain medicine​ Personal protective equipment (PPE) Clean gloves Cotton-tipped applicators Measuring device

Immunity that is __________ may result in severe infection. Immunity that is __________ may result in allergies or autoimmune diseases.

Suppressed Exaggerated

Select the assessment findings that require immediate follow-up.​ The nurse is caring for a client with diabetes mellitus type 1 who is 72 hours postoperative surgical removal of the descending colon and rectum with the placement of a transverse colostomy. During the assessment, the client has a temperature of 102.6 °F (39.2 °C) and increasing amounts of purulent, serosanguineous drainage from the abdominal incision. The client reports pain of 10/10 to the abdominal incision.

Temperature of 102.6 °F (39.2 °C) Purulent, serosanguineous drainage Pain of 10/10

Which outcomes are appropriate for a bedfast client with a duodenal feeding tube admitted with a pressure ulcer? Select all that apply.​

The signs of healing will increase in the current wound. The intact skin will remain intact until discharge.

The nurse is completing a skin assessment on Jan (pronouns: she, her), who lives in a nursing care facility after a stroke left her unable to care for herself. Jan developed a pressure ulcer on her coccyx after being in bed for a week with influenza. ​ Select all the findings that require follow-up by the nurse. The wound is 8 cm along the vertical axis, 14.5 cm along the horizontal axis, and 4 cm deep; a moderate amount of thick, yellow-tan, foul-smelling drainage noted at the 9-1 o'clock position and on the old dressing; the wound bed is bleeding between the 5-7 o'clock position. ​Client moans when wound is touched. ​

Thick, yellow-tan, foul-smelling drainage

Which body fluids transmit human immunodeficiency virus (HIV)? Select all that apply.

Vaginal fluid Semen Breast milk Blood

An experienced nurse notices that wearing gloves results in skin redness, urticaria, and rhinitis almost immediately. What actions should the nurse take? Select all that apply.

Wear a Medic Alert bracelet. Immediately remove the gloves and wash your hands. Maintain access to an epinephrine pen. Avoid peaches, kiwis, and avocados.

The nurse is caring for a client with diabetes mellitus type 1 who is 72 hours postoperative surgical removal of the descending colon and rectum with the placement of a transverse colostomy. During the assessment, the client has a temperature of 102.6 °F (39.2 °C) and increasing amounts of purulent, serosanguineous drainage from the abdominal incision. The client reports pain of 10/10 to the abdominal incision. The client is at the highest risk of developing __________ and __________.

Wound dehiscence Deep vein thrombosis