Chapter 3: Inflammation, the Inflammatory Response, and Fever

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 the a normal range. Select the result that suggests the client is now within normal range. a. 4000 to 10,000 cells/mcL b. 14,000 to 20,000 cells/mcL c. 1500 to 20,000 cells/mcL d. 1000 to 3000 cells/mcL

a. 4000 to 10,000 cells/mcL (Explanation: A normal value of white blood cells would be 4000 to 10,000 cells/mcL. In acute inflammatory, the white blood count commonly increases from 15,000 to 20,000 cells/mcL. The other results are abnormal.)

A client has been diagnosed with a FUO fever of unknown cause; the nurse recognizes this as: a. A prolonged fever that does not have an identified source b. A fever that only occurs in adults c. A fever of new onset d. A fever that has responded well to several medications

a. A prolonged fever that does not have an identified source (Explanation: A prolonged fever for which the cause is difficult to ascertain is often referred to as fever of unknown origin [FUO]. FUO is defined as a temperature elevation of 38.3°C [101°F] or higher that is present for 3 weeks or longer. An FUO can occur in children or adults.)

Select the response that best describes a granulomatous inflammatory response to a foreign body: a. Connective tissue encapsulates it and isolates it for removal. b. Macrophages attack the foreign object to dissolve it. c. Normal inflammatory mechanisms to act on the foreign body. d. Foreign body to be digested and dissolved.

a. Connective tissue encapsulates it and isolates it for removal. (Explanation: Granulomatous inflammatory response to a splinter would involve the connective tissue encapsulating and isolating it for the removal. Each of the other options is part of the normal inflammatory response and would not apply in this situation.)

A client is suspected to have developed chronic inflammation. Select the potential causes of the chronic condition. Select all that apply: a. Tubercle bacillus b. Talc c. Asbestos d. Penetrating trauma e. Silica f. Suture

a. Tubercle bacillus b. Talc c. Asbestos e. Silica f. Suture (Explanation: Among the causes of chronic inflammation are foreign agents such as talc, silica, asbestos, and surgical suture materials. Many viruses provoke chronic inflammatory responses, as do certain bacteria, such as the tubercle bacillus and Actinomyces, as well as fungi, and larger parasites. Acute inflammation can be triggered by a variety of stimuli, including infections, immune reactions, blunt and penetrating trauma, and physical or chemical agents.)

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): a. Ulceration b. Abscess c. Pustule d. Fungus

a. Ulceration (Explanation: Ulceration refers to a site of inflammation where an epithelial surface [e.g., skin or gastrointestinal epithelium] has become necrotic and eroded, often with associated subepithelial inflammation. Ulceration may occur as the result of traumatic injury to the epithelial surface [e.g., peptic ulcer] or because of vascular compromise [e.g., foot ulcers associated with diabetes]. The other options do not present these manifestations.)

An older adult's dysfunctional temperature regular function places the client at greatest risk to: a. Acute dementia b. Delayed initiation of appropriate treatment c. Misdiagnosis of pathology d. Acute renal failure

b. Delayed initiation of appropriate treatment (Explanation: The elderly often have a lower baseline temperature [36.4°C or 97.6°F] than younger persons, and although their temperature increases during an infection, it may fail to reach a level that is equated with significant fever. Absence of fever does not result in misdiagnosis. While the remaining options may occur, they are not the greatest risks for injury.)

The nurse is assessing a client who is in the prodromal stage of a fever. The nurse anticipates the client will exhibit: a. Reddened skin b. Fatigue c. Diaphoresis d. Shivering

b. Fatigue (Explanation: The reactions that occur during fever consists of four stages: a prodromal period with nonspecific complaints, such as mild headache and fatigue; a chill, during which the temperature rises; a flush, during which the skin becomes warm and flushed; and a defervescence stage, which is marked by the initiation of sweating.)

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: a. Coolness b. Redness c. Decreased sensation at the site d. Increased bacterial infection

b. Redness (Explanation: Vasodilation of the arterioles and congestion of the capillary beds result in an increased pooling of blood leading to redness. The site would also have increased painful sensation and be warmer to touch. It would not result in an increase in bacterial load.)

A client has developed systemic inflammatory response syndrome. The nurse is aware that this results from: a. Anaphylactic shock b. Severe bacterial infections (sepsis) c. Respiratory arrest d. Acute renal failure

b. Severe bacterial infections (sepsis) (Explanation: In severe bacterial infections [sepsis], large quantities of microorganisms in the blood result in the production and release of enormous quantities of inflammatory cytokines and development of what is referred to as the systemic inflammatory response syndrome. Systemic inflammatory response syndrome results in generalized vasodilation, increased vascular permeability, intravascular fluid loss, myocardial depression, and fatal circulatory shock.)

A client who has developed a fever is now complaining of a headache. The nurse would recognize this manifestation as result from the: a. Vasoconstriction of cerebral vessels b. Vasodilatation of cerebral vessels c. Vasoconstriction of coronary vessels d. Vasodilatation of coronary vessels

b. Vasodilatation of cerebral vessels (Explanation: Headache is a common accompaniment of fever and is thought to result from the vasodilatation a cerebral vessels occurring with fever. The coronary arteries would not contribute/cause the headache.)

The parents of a 2-year-old child ask the nurse why their child is more susceptible to viral infections than their older children. The best response would be: a. "The younger child has a diminished ability to practice hand-washing effectively." b. "The younger child has an immature renal system that makes taking antiviral drugs dangerous." c. "The younger child has an immature immune system." d. "The younger child has downward slopping ear canals that are predisposed to infections."

c. "The younger child has an immature immune system." (Explanation: Infants and young children have decreased immunologic function and are more commonly infected with virulent organisms. The remaining options are not viable risk factors for increased viral infection risk.)

Select the option that best describes an observable physiological behavior exhibited by an individual attempting to conserve body heat. a. Oliguria b. Sweating c. Adducting the extremities d. Shivering

c. Adducting the extremities (Explanation: Body positions that hold the extremities close to the body [e.g., huddling] prevent heat loss and are commonly assumed in cold weather. Decreasing the production of urine has no direct impact on conserving body, while shivering produces and sweating dissipates heat.)

A client asks the nurse what is the most common objective symptom of systemic inflammation during the acute-phase response. The best response would be: a. Edema b. Palpable lymph nodes c. Fever d. Diarrhea

c. Fever (Explanation: The most prominent observable systemic manifestations of inflammation during the acute-phase response is fever. Painful palpable nodes are commonly associated with a systemic inflammatory process; fever is more often recognized. Edema is a characteristic of a localized inflammation, while diarrhea is not generally recognized as a sign of inflammation unless specifically related to the GI system.)

The nurse is caring for a client whose temperature is increasing. The nurse is aware that the client will also experience an increase in: a. Respiratory rate b. Blood pressure c. Heart rate d. White blood cell count

c. Heart rate (Explanation: Critical to the analysis of a fever pattern is the relation of heart rate to the level of temperature elevation. Normally, a 1°C rise in temperature produces a 15 bpm [beats/minute] increase in heart rate [1°F, 10 bpm]. The remaining options are not as closely related as is heart rate.)

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

c. 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 typically increased as part of the inflammatory process.)

A nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for: a. Cyanosis, heat, and swelling b. Paresthesia, redness, and coolness c. Rubor, swelling, and pain d. Pain, pulselessness, and edema

c. Rubor, swelling, and pain (Explanation: The classic signs of inflammation are rubor [redness], tumor [swelling], calor [heat], and dolor [pain]. The remaining options are more characteristic of symptomatology resulting from circulatory dysfunction.)

Select the most accurate and comfortable route for the nurse to assess the temperature of an elderly client: a. Rectal route b. Oral route c. Tympanic route d. Axillary route

c. Tympanic route (Explanation: Oral temperature remains the most commonly used method for measuring temperature in the elderly. It has been suggested that rectal and tympanic membrane methods are more effective in detecting fever in the elderly with the tympanic route being the most comfortable. Axillary temperature is not considered very accurate.)

Select the most likely source of a fever in a 16-month-old female child. a. Otitis media b. Respiratory infection c. Urinary tract infection d. Teething

c. Urinary tract infection (Explanation: Febrile children who are less than 1 year of age and females between 1 and 2 years of age should be considered at risk for a urinary tract infection.)

The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as: a. Exudate containing large amounts of fibrinogen b. Exudate that resulted from leakage of red cells c. Exudate that is watery fluid, low in protein d. Exudate containing white blood cells, protein, and tissue debris

d. Exudate containing white blood cells, protein, and tissue debris (Explanation: A purulent or suppurative exudate contains pus, which is composed of degraded white blood cells, proteins, and tissue debris. Fibrinous exudates contain large amounts of fibrinogen. Serous exudates are watery fluids low in protein. Hemorrhagic exudates occur when there is severe tissue injury that causes damage to blood vessels or when there is significant leakage of red cells.)

A client has a watery fluid leaking from a site of inflammation. The nurse would document this type of exudate as: a. Hemorrhagic b. Fibrinous c. Suppurative d. Serous

d. Serous (Explanation: Serous exudate is a watery fluid low in protein content that results from plasma entering the inflammatory site. Hemorrhagic exudate is red or blood tinged related to damage to blood vessels. Suppurative exudate is composed of degraded white blood cells and tissue debris, leaving the fluid pus-like. Fibrinous is thick and sticky meshwork fluid.)