Immune PrepU

flush state

and the third stage is the ....

Fever stages

prodrome, chill, flush, defervescence

the chills

the second stage is marked by ___

fever patterns

An intermittent fever is one in which temperature returns to normal at least once every 24 hours. In a remittent fever, the temperature does not return to normal and varies a few degrees in either direction. In a sustained or continuous fever, the temperature remains above normal with minimal variations (usually <0.55°C or 1°F). In recurrent or relapsing fever, there is one or more episodes of fever, each as long as several days, with one or more days of normal temperature between episodes.

The nurse evaluates which core body temperature as outside the normal range? Select all that apply. 36.2°C (97.1°F) 37.4°C (99.3°F) 96.8°F (36°C) 99.6°F (37.5°C)

Correct response: 96.8°F (36°C) 99.6°F (37.5°C) Explanation: The normal range for core body temperature is 36°C to 37.5°C, or 96.8°F to 99.5°F.

In the vascular phase of acute inflammation, initial vasoconstriction is followed rapidly by which assessment finding? Bleeding Heat and redness Infiltration of leukocytes Cool, dry skin

Correct response: Heat and redness Explanation: The vascular phase of acute inflammation is characterized by changes in the small blood vessels at the site of injury. It begins with momentary vasoconstriction followed by rapid vasodilation, which allows more blood and fluid into the area of injury, resulting in congestion, redness, and warmth. As fluid moves out of the vessels, stagnation of flow and clotting of blood occurs.

During the acute inflammatory response, there is a period called the transient phase where there is increased vascular permeability. What is considered the principal mediator of the immediate transient phase? Histamine Arachidonic acid Fibroblasts Cytokines

Correct response: Histamine Explanation: Histamine causes dilation of arterioles and increases the permeability of venules. It acts at the level of the microcirculation by binding to histamine 1 receptors on endothelial cells and is considered the principal mediator of the immediate transient phase of increased vascular permeability in the acute inflammatory response. Arachidonic acid is a 20-carbon unsaturated fatty acid found in phospholipids of cell membranes. Release of arachidonic acid by phospholipases initiates a series of complex reactions that lead to the production of the eicosanoid family of inflammatory mediators (prostaglandins, leukotrienes, and related metabolites). Fibroblasts and cytokines are not the principal mediator of the transient phase of an acute inflammatory response.

fever extra info

During the first or prodromal period, there are nonspecific complaints such as mild headache and fatigue, general malaise, and fleeting aches and pains. During the second stage or chill, there is the sensation of being chilled and the onset of generalized shaking (rigors), despite temperature rising. Vasoconstriction and piloerection usually precede the onset of shivering. The skin is pale and there is a drive to conserve body heat. Once the body temperature reaches the new set point, the shivering ceases and a sensation of warmth develops. At this point, the third stage or flush begins, during which cutaneous vasodilation occurs and the skin becomes warm and flushed. The fourth, or defervescence, stage of the febrile response is marked by the initiation of sweating. Not all people proceed through the four stages of fever development.

pyrogens

Pyrogens are exogenous or endogenous substances that produce fever. Exogenous pyrogens are from outside the body and include bacterial products, bacterial toxins, or whole microorganisms. Exogenous pyrogens induce host cells to produce fever-producing mediators called endogenous pyrogens. When bacteria or breakdown products of bacteria are present in blood or tissues, phagocytic cells of the immune system engulf them, digest the bacterial products, and release pyrogenic cytokines into the bloodstream for transport to the hypothalamus, where they exert their action.3 These cytokines induce prostaglandin E2 (PGE2).31 At this point, PGE2 binds to receptors in the hypothalamus to induce increases in the thermostatic set point. The hypothalamus then initiates shivering and vasoconstriction that raise the body's core temperature to the new set point, and fever is established.

headache and body aches

The first stage of a fever is marked by ....

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 Remittent Erratic Relapsing

Correct response: Intermittent Explanation: Intermittent fever patterns are very changeable, but they do return to normal at least once every 24 hours. A remitting fever pattern temperature does not return to normal and varies a few degrees in either direction. In a sustained fever pattern, the temperature remains above normal with minimal variations. A relapsing fever is one in which there is one or more episodes of fever, each as long as several days, with 1 or more days of normal temperature between episodes.

A client's temperature readings are as follows: 99.6°F (37.5°C) at 4 pm; 102°F (38.9°C) at 8 pm; and 97.9°F (36.6°C) at 12 am. The nurse's hand-off should include which note? Intermittent fever Prodromal phase Remittent fever Defervescence

Correct response: Intermittent fever Explanation: The nurse's hand-off report should include the presence of intermittent fever—a temperature that returns to normal at least once every 24 hours.

The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation? Loss of function Altered level of consciousness Sepsis Fever

Correct response: Loss of function Explanation: These signs are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). In the second century AD, the Greek physician Galen added a fifth cardinal sign, functio laesa (loss of function). Altered level of consciousness is not a cardinal sign of inflammation. Sepsis and fever are systemic signs of infection.

A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. 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 (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg T 99.7ºF (37.6°C), P 86/min, R 18/min, BP 130/82 mm Hg T 98.4ºF (36.9°C), P 82/min, R 16/min, BP 106/70 mm Hg T 97.2ºF (36.2°C), P 70/min, R 12/min, BP 114/60 mmHg

Correct response: T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg Explanation: During the chill phase of fever, the client feels cold and may experience pale skin with goosebumps, but the temperature is rising. When the body reaches the new set point, shivering will stop, and flushing will begin.

The nurse notes the client has developed a systemic response of inflammation based on assessment findings. Which clinical manifestations support this diagnosis? Select all that apply. Temperature of 100.9°F (38.3°C) Somnolence Generalized achiness Decreased capillary permeability Pounding, throbbing headache

Correct response: Temperature of 100.9°F (38.3°C) Somnolence Generalized achiness Explanation: Manifestations of the acute-phase response include fever, anorexia, somnolence, and malaise. One would expect to see increased (not decreased) capillary permeability with acute inflammatory response. Throbbing headache is not an acute 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? First Second Third Fourth

Correct response: Third Explanation: The first stage of a fever is marked by headache and body aches, the second stage is marked by the chills, and the third stage is the flush state. The fourth stage is defervescence.

A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as a/an: increase in cell production. increase in circulating neutrophils. decrease in blood supply to the affected area. decrease in eosinophils at the tissue injury site.

Correct response: increase in circulating neutrophils. Explanation: Leukocytosis, or the increase in white blood cells, is a frequent sign of an inflammatory response, especially those caused by bacterial infection. Leukocytosis occurs due to an increase in circulating neutrophils and eosinophils. Leukocytosis does not occur because of increased cell production, and blood supply is typically increased as part of the inflammatory process.

While sponging a client who has a high temperature, the nurse observes the client begins to shiver. At this point, the priority nursing intervention would be to: administer an extra dose of aspirin. stop sponging the client and retake a set of vital signs. increase the room temperature by turning off the air conditioner and continue sponging the client with warmer water. place a heated electric blanket on the client's bed.

Correct response: stop sponging the client and retake a set of vital signs. Explanation: Modification of the environment ensures that the environmental temperature facilitates heat transfer away from the body. Sponge baths with cool water or an alcohol solution can be used to increase evaporative heat losses. More profound cooling can be accomplished through the use of a cooling blanket or mattress, which facilitates the conduction of heat from the body into the coolant solution that circulates through the mattress. Care must be taken so that cooling methods do not produce vasoconstriction and shivering that decrease heat loss and increase heat production.