Patho 3

A client 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 client's physician has ordered a complete blood count and white cell differential. Which blood component would the physician most likely anticipate to be elevated?

Neutrophils

A 24-year-old woman presents with fever and painful, swollen cervical lymph nodes. Her blood work indicates neutrophilia with a shift to the left. She most likely has:

A severe bacterial infection

A client's body temperature has been documented as follows: 12 noon: 37°C (98.6°F); 6 pm: 37.5°C (99.5°F); 3 am: 36°C (96.8°F). Which action should the nurse take?

Document the temperature.

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 client with a rising temperature is pale and has begun to shiver. The nurse reports that the client is in which phase of fever development?

Chill

The nurse is assessing a client with an elevated temperature. Which additional assessment findings provide the most useful information for the nurse?

Client's heart rate is more rapid than anticipated.

A client has a splinter. The nurse expects a granulomatous inflammatory response. What does this involve?

Connective tissue encapsulating and isolating the splinter

A nurse assessing an older adult for signs and symptoms of infection in the absence of a fever should assess for which of the following?

Decreased mental status Change in fuctional capacity Fatigue

A client has an increase in core temperature. What does the nurse expect to assess with this finding?

Dilation of superficial blood vessels Sweating

A nurse is providing care for a 44-year-old male client who is admitted with a diagnosis of fever of unknown origin (FUO). Which characteristic of the client's history is most likely to have a bearing on his current diagnosis?

HIV positive and homeless

Neurogenic fevers begin in the central nervous system. By what characteristics are neurogenic fevers known?

High temperatures that are not associated with sweating

A deficiency in which of these would result in an inhibition of the inflammatory response?

Histamine

A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?

Notify the physican.

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

Rubor, swelling, and pain

The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis?

Sepsis

A client has a watery fluid leaking from a site of inflammation. The nurse would document this type of exudate as:

Serous

Fever in infants and young children is not an uncommon event. Many trips to the pediatrician's office occur because of fever in children ages 1 day to 3 years. Which sign or symptom does not indicate fever in an infant?

avid feeding

Which client is most likely to have impairments to the wound healing process? A client with:

poorly controlled blood sugars with small blood vessel disease.

A client presents with an oral temperature of 101.7°F (38.7°C) and painful, swollen cervical lymph nodes. Laboratory results indicate neutrophilia with a shift to the left. Which diagnosis is most likely?

severe bacterial infection

A client who has developed a fever is now reporting a headache. The nurse would recognize this manifestation as a result from the:

vasodilatation of cerebral vessels.

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

Leukocytosis

A health educator is teaching a group of colleagues about the physiology of thermoregulation. Which statement is most accurate?

"Prostaglandin E2 (PGE2) exerts a direct fever-producing effect on the hypothalamus."

A nurse educator is describing the way that cells involved in the inflammatory response find their way to the site of injury. Which description best reflects this physiologic mechanism?

"The process of chemotaxis is the process where cells wander through the tissue guided by secreted chemoattractants."

Which temperature readings indicate to the nurse that the clients have fever?

35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) 19-year-old with oral reading of 38.4ºC (101.1ºF) 3-day-old with rectal reading of 38ºC (100.4ºF)

A nurse instructing unlicensed assistive personnel (UAP) on temperature regulation includes as part of her teaching that core body and skin temperatures are sensed by which part of the brain?

Hypothalamus

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

Neurogenic

Which client manifestation indicates signs of drug fever?

Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis

Inflammation can be either local or systemic. What are the most prominent systemic manifestations of inflammation?

Fever, leukocytosis or leukopenia, and the acute phase response

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

increase in circulating neutrophils.

What can the nurse tell a client about antipyretic drugs during fever?

"Antipyretics help to protect the body."

The loss of heat from the body through the circulation of air currents is known as:

Convection

A client has been diagnosed with a fever of unknown cause. The nurse recognizes this as:

A prolonged fever that does not have an identified source

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

Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?

Apply cooling blanket

An agricultural worker is picking fruit on a day when the air temperature is 106°F (41.1°C). Which process will most likely be occurring while he works?

Blood volume to his skin surface will be increasing to dissipate heat.

Drug fever is a fever that can occur with the administration of a specific drug and then disappear when the drug is discontinued. Which method indicates a way that drugs can induce fever?

Drugs can act as direct pyrogens. Drugs can induce an autoimmune response. Drugs can injure tissues directly.

A nurse who is providing a staff development in-service determines that the participants understand the information when they state that which bodily function aids heat conservation by reducing surface area for heat loss?

Erection of pilomotor muscles

Which diagnostic lab test is used to diagnose the presence of inflammation?

Erythrocyte sedimentation rate

A client is being treated for a pressure ulcer and the care team has observed that the wound is healing. Which activity will take place during the proliferative phase?

Fibroblasts secrete the cells necessary for wound healing

A client has an increase in core body temperature. What assessment finding does the nurse expect?

Flushed skin

What is the most common cause of drug fever?

Hypersensitivity reaction to medication

When educating a client with a wound that is not healing, the nurse should stress which dietary modifications to ward off some of the negative manifestations that can occur with inflammation?

Increase your intake of oily fish and fish oil so that you will increase absorption of omega-3 polyunsaturated fatty acids.

A client undergoes a splenectomy following an automobile accident. The nurse monitors for which anatomical change most likely to occur following surgery?

Increased white blood cell (WBC) count

In which client with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation?

Injury at T2

Most febrile illnesses are due to common infections and are relatively easy to diagnose. In certain instances, however, it is difficult to establish the cause of a fever. In these instances, the elevation in temperature is referred to as a fever of unknown origin (FUO). What is a common cause of FUO?

Malignancies

Place the four successive stages of fever in correct order.

Prodromal Chill Flush Defervescence

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:

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

nurse reading a client's history and physical notes that the client has had a remitting fever. The nurse interprets this to mean that the client's temperature has done what?

Remained elevated but varied a few degrees

A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the client's temperature on admission and finds that it is 96.6°F (35.9°C). Which statement describes how the nurse should interpret the finding?

The client may 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

Purulent exudate contains which substances?

Tissue debris White blood cell by-products

A nurse notes that a client with a fever has begun to shiver. The nurse should assess for which event?

Increased temperature

An older adult client with a history of chronic obstructive pulmonary disease (COPD) develops a fever of 38.3ºC (101ºF). What is the primary reason for the nurse to implement temperature-lowering measures?

Reduce oxygen demand

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

The nurse is assessing a client with diabetes and notes an area on the client's right foot as inflamed, necrotic, and eroded. The client states he accidentally slammed his foot in a door 2 weeks ago. The nurse would document this finding as a(n):

Ulceration

Which process would most likely be considered an anomaly during the cellular phase of inflammation?

Vasoconstriction

The nurse is caring for a client with an elevated temperature. Which of the following other symptoms might the nurse expect the patient to be experiencing?

Weakness Fatigue

Which clients are showing manifestations of infection?

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

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

Edema

The cells that are associated with allergic disorders and the inflammation associated with immediate hypersensitive reactions are known as what?

Eosinophils Mast cells Basophils

A client tells the nurse that she was treated at a local urgent care center for a bacterial infection that caused a temperature of 102.5°F (39.1°C). The nurse documents:

Exogenous pyrogen

A client with environmental allergies is experiencing respiratory inflammation. Which mediator causes vasodilation during the vascular stage of the inflammatory response?

Histamine

Which aspect of a client's site of inflammation would help the care provider rule out chronic inflammation?

Increased neutrophils

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

The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation?

Loss of function

While a nurse is taking a client's history, the client states that he had a fever 2 days ago that went away for a day and then returned. The nurse documents this as being which type of fever?

Relapsing

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.

A client diagnosed with bacterial pneumonia has an increase in the number of bands in the white blood cell count. Which is the priority action of the nurse?

Continuing to monitor the client's laboratory results; this is an expected finding in an acute infection.

Pyrogens are substances that produce fever in the body. Substances such as bacterial products, bacterial toxins, or whole microorganisms enter the body and stimulate the host cells to produce certain mediators. What are these called?

Endogenous pyrogens

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

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

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

Prodrome

A client reports having three episodes of fever that have lasted several days, with periods of normal temperature in between the episodes for 2 or more days. Which type of fever is the client experiencing?

Relapsing fever

A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for:

Temperature

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

A client is said to be in the chill stage of the fever process when the nurse:

observes piloerection on the skin.