Pathophysiology chapter 3
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?
A severe bacterial infection
Why is the risk of scarring and deformity greater in chronic inflammation than it is in acute inflammation?
Fibroblasts instead of exudates proliferate in chronic inflammation.
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?
Hypothalmus
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?
Neutophils
Which client manifestation indicates signs of drug fever?
Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis
A client is said to be in the chill stage of the fever process when the nurse:
observes piloerection on the skin.
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 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
A client who has developed a fever is now reporting a headache. The nurse would recognize this manifestation as a result from the: You Selected:
vasodilatation of cerebral vessels.
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? Select all that apply.
-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)
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 pregnant client comes to the clinic with symptoms of body aches, headache, and fatigue. A physical assessment reveals enlarged lymph nodes. A diagnosis of toxoplasmosis with chronic inflammation caused by a parasitic organism is determined. Which assessment findings would most likely also be present? Select all that apply.
-Cysts due to granuloma formation -Increase in eosinophil count -Increase in eosinophil count
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? Select all that apply. You Selected:
-Decreased mental status -Change in fuctional capacity -Fatigue
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 client is experiencing pain -The ankle is warmer than the unaffected ankle -The client's ankle is visibly red
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 has been diagnosed with a fever of unknown cause. The nurse recognizes this as:
A prolonged fever that does not have an identified source
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 intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?
Apply cooling blanket
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
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 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.
The loss of heat from the body through the circulation of air currents is known as
Convection
A client taking the typical antipsychotic agent haloperidol experiences neuroleptic malignant syndrome. What nursing intervention is highest priority after stopping the medication?
Cooling blanket
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. Explanation:
The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess?
Edema
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
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
Inflammation can be either local or systemic. What are the most prominent systemic manifestations of inflammation? You Selected:
Fever, leukocytosis or leukopenia, and the acute phase response
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 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?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
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
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.
Which aspect of a client's site of inflammation would help the care provider rule out chronic inflammation?
Increased neutrophils
A nurse notes that a client with a fever has begun to shiver. The nurse should assess for which event?
Increased temperature
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
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'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 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
The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation?
Loss of function
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? You Selected:
Malignancies
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.
Place the four successive stages of fever in correct order.
Prodromal Chill Flush Defervescence
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 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."
The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading?
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
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 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
The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis?
Sepsis
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 Correct response:
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.
Which client should be assessed for fever based on other presenting symptoms? Select all that apply
The client with anorexia The client with myalgia
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? You Selected:
Vasoconstriction
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.
