201 PrepU - Chapter 3: Inflammation, the Inflammatory Response, and Fever

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

- 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

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.

- Decreased mental status - Change in functional capacity - Fatigue

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)

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

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 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

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?

Applying the 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

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

Edema

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

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

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

Histamine

What is the most common cause of drug fever?

Hypersensitivity reaction to medication

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

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 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

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

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 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 physician

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

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

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 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

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

Temperature

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

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

Vasoconstriction

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 in the wound healing process? A client with:

poorly controlled blood sugars with small blood vessel disease.