Chapter 3: Inflammation, the Inflammatory Response, and Fever http://thepoint.lww.com/Book/Show/Level 3
A client has been diagnosed with a FUO fever of unknown cause; the nurse recognizes this as: a) A fever of new onset b) A fever that only occurs in adults c) A prolonged fever that does not have an identified source d) A fever that has responded well to several medications
A prolonged fever that does not have an identified source 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.
A client presents with an oral temperature of 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 -Fever and painful, palpable lymph nodes are nonspecific inflammatory conditions; -leukocytosis is also common but is a particular hallmark of bacterial infection. -Neutrophilia also indicates a bacterial infection, whereas increased levels of other leukocytes would indicate other etiologies. -The shift to the left---the presence of many immature neutrophils---indicates that the infection is severe, because the demand for neutrophils exceeds the supply of mature cells.
A patient with a rising temperature is pale and has begun to shiver. The nurse reports that the patient is in which of the following phases of fever development? a) Defervescence b) Prodrome c) Chill d) Flush
Chill During the second phase or chill phase of fever development, the patient's skin is pale; there is an onset of shivering, a rising temperature, and the sensation of being chilled. Therefore, the nurse should report that the patient is in the second or chill phase of fever development.
The nurse is assessing a client for acute inflammation of a wound. For which of these symptoms of infection does the nurse assess? a) Tissue necrosis b) Hypothermia c) Edema d) Pallor
Edema Cardinal signs of inflammation include rubor (redness), tumor (swelling or edema), calor (heat), dolor (pain) and functio laesa (loss of function). -Tissue necrosis occurs with chronic inflammation
A client has an increase in core body temperature. What assessment findings does the nurse expect? a) Flushed skin b) Decreased skin temperature c) Blue nail beds d) Decreased urination
Flushed skin The client with an increase in their core temperature will be accompanied by flushed, warm skin as the body tries to lower the temperature. -The other assessments do not correlate with increased core temperature.
A patient has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for the patient with which of the following types of fever? a) Exdogenous b) Neurogenic c) Systemic d) Intrinsic
Neurogenic Neurogenic fever has its origin in the central nervous system and is usually caused by damage to the hypothalamus from trauma, intercranial bleeding, or increased intercranial pressure. The nurse should plan care for a patient with a neurogenic fever.
Which of the following patients is most likely to have impairments to the wound healing process? A patient with: a) A diagnosis of multiple sclerosis and consequent impaired mobility. b) Congenital heart defects and anemia. c) Poorly controlled blood sugars with small blood vessel disease. d) Chronic obstructive pulmonary disease.
Poorly controlled blood sugars with small blood vessel disease. Diabetes mellitus is strongly associated with impaired wound healing. The other noted pathologies are less causative of deficiencies in the healing process.
The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading? a) Rectal b) Axillary c) Oral d) Forehead
Rectal Measurement of core body temperature is important when evaluating fever. The rectal route is considered the most accurate. In adults and older children, the oral route is lower, but still accurate; however, in young children the oral route may be unreliable. -Forehead thermometers can predict trends, but are not as accurate as other routes. -The axillary route requires up to 10 minutes for the temperature to register appropriately.
The nurse is attempting to obtain the most accurate core body temperature of a patient. Which of the following methods should the nurse use? a) Oral b) Rectal c) Axillary d) Ear based
Rectal The rectal temperature is considered the most accurate parameter for measuring core body temperature compared to oral, axillary, and ear based.
The route considered the most accurate to measure a core body temperature is which of the following? a) Thermosensoral (bladder) b) Thermodilutional (pulmonary artery) c) Rectal d) Esophageal
Rectal The rectal temperature is used as a measure of core temperature and is least invasive of all of these options.
A client has a watery fluid leaking from a site of inflammation. The nurse would document this type of exudate as: a) Fibrinous b) Serous c) Suppurative d) Hemorrhagic
Serous 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 exudate is thick and sticky meshwork fluid.
A client with pneumonia is admitted with these vital signs: temperature 99.7ºF, pulse 80 beats/min, respirations 18/minute, and BP 120/80 mmHg. 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, P 90/min, R 20/min, BP 126/80 mmHg 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.
A patient is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for which of the following? a) Respirations b) Hypothermia c) Urinary output d) Temperature
Temperature Common clinical manifestations of fever include anorexia, myalgia, arthralgia, headaches, and fatigue; thus, the nurse should assess the patient's temperature.
A hospital client who is being treated for acute kidney injury has developed an oral temperature of 39.1°C (102.4°F) despite the absence of other signs and symptoms of infection. When attempting to determine the etiology of the client's fever, the nurse should: a) auscultate the client's apical heart rate for at least 1 minute. b) measure the client's lying, sitting, and standing blood pressure. c) auscultate the client's lungs and facilitate lung function testing. d) review the client's recent medication history.
review the client's recent medication history. Drugs are a frequent cause of fevers that are unrelated to infection. For this reason, a review of the client's medication history would likely be prioritized over vital signs, provided the client is not in immediate distress.
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. a) Decreased mental status b) Change in fuctional capacity c) Fatigue d) Depression e) Weight gain
• Decreased mental status • Change in fuctional capacity • Fatigue Signs and symptoms of infection in an older adult in the absence of a fever include decreases in mental status and functional capacity, fatigue, weight loss, and weakness.
A client presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after working outside in a hot day. Which assessment findings suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature? Select all that apply. a) Pallor b) Cognitive changes c) Shivering d) Dizziness e) Moist skin
• Shivering • Pallor Shivering is a response to a signal for increased heat production. It would only occur on a hot day if the set point for temperature regulation were increased, as in the case of fever but not hyperthermia. Similarly, pallor is more closely associated with an infection causing fever than hyperthermia. -Moist skin, cognitive changes, and dizziness can occur with either fever or hyperthermia.
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. a) The ankle is bleeding b) The ankle is warmer than the unaffected ankle c) The client is experiencing pain d) The ankle appears to be swollen e) The client's ankle is visibly red
• The ankle is warmer than the unaffected ankle • The client is experiencing pain • The ankle appears to be swollen • The client's ankle is visibly red The cardinal signs of inflammation are rubor (redness), tumour (swelling), calor (heat), and dolor (pain). -Bleeding is not among the cardinal signs.
A nurse's hand-off reports states that the patient has pyrexia. The nurse plans care for the patient with which of the following events? a) Fever b) Incontinence c) Wound d) Rash
Fever When a patient is documented to have pyrexia, the nurse should plan care for a patient with a fever.
A client who has developed a fever is now complaining of a headache. The nurse would recognize this manifestation as a result from the:
Vasodilatation of cerebral vessels Headache is a common accompaniment of fever and is thought to result from the vasodilatation of cerebral vessels occurring with fever. The coronary arteries would not contribute/cause the headache.
Which client most likely faces the highest risk of neuroleptic malignant syndrome?
Young adult client who is taking antipsychotic medications for the treatment of schizophrenia. Antipsychotics are often implicated in cases of neuroleptic malignant syndrome. Surgery, medications for Alzheimer disease and fever are not risk factors.
Which of the following can the nurse tell a patient about antipyretic drugs during fever? a) "They are not recommended." b) "Antipyretics are ineffective in most cases." c) "They usually have little effect." d) "Antipyretics help to protect the body."
"Antipyretics help to protect the body." Antipyretic drugs are given to alleviate the discomfort of fever and protect vulnerable organs, such as the brain from extreme elevations in body temperature. They are usually effective
A client asks why his temperature is always below 98.6°F. The nurse responds: a) A person's highest point of core temperature is usually first thing in the morning. b) The best way to bring your body temperature up to normal is to live in a warmer climate. c) Some people maintain a core body temperature of 41°C and that is normal for them. d) Normal core temperature varies between individuals within the range of 97.0°F to 99.5°F.
Normal core temperature varies between individuals within the range of 97.0°F to 99.5°F. Core temperature is normally maintained within a range of 36.0°C to 37.5°C (97.0°F to 99.5°F). -A core temperature greater than 41°C (105.8°F) or less than 34°C (93.2°F) usually indicates that the body's thermoregulatory ability is impaired. - Body heat is generated in the tissues of the body, transferred to the skin surface by the blood, and then released into the environment surrounding the body. -The thermoregulatory center regulates the temperature of the deep body tissues, or "core" of the body, rather than the surface temperature. -Internal core temperatures reach their highest point in late afternoon and evening and their lowest point in the early morning hours.
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? a) Fourth b) Second c) First d) Third
Third 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.
Which symptom indicates the next stage of a fever after a prodrome? a) Predrome b) A chill c) A flush d) Defervescence
A chill The physiologic behaviors that occur during the development of fever can be divided into four successive stages: prodrome, chill, flush, and defervescence. The stages are successive.
An older adult's dysfunctional temperature regulator function places the client at greatest risk for: a) Misdiagnosis of pathology b) Delayed initiation of appropriate treatment c) Acute renal failure d) Acute dementia
Delayed initiation of appropriate treatment The elderly often have a lower baseline temperature (36.4°C [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. - The absence of fever may delay diagnosis and initiation of antimicrobial treatment. -Absence of fever does not result in misdiagnosis. -While the remaining options may occur, they are not the greatest risks for injury.
In which of the following patients with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation? a) Injury at T2 b) Injury at T9 c) Injury at L1 d) Injury at L4
Injury at T2 Spinal cord injuries that transect the cord at T6 or above can seriously impair temperature regulation because the thermoregulatory centers in the hypothalamus can no longer control skin blood flow and sweating. T9, L4, and L1 injuries are below the level of T6 and do not impair the hypothalamus' ability to control skin blood flow and sweating.
A two-day postoperative patient's temperature was 98.5°F at 3:00 pm. At 6:00 pm, the unlicensed assistant notifies the nurse that the patient's temperature is 102.0°F. Which of the following actions should the nurse take? a) Offer the client a cold drink b) Notify the physican c) Increase intravenous fluid rate d) Document the temperature
Notify the physician The nurse should contact the physician, as the increase in the patient's temperature is outside of the normal range and/or the normal diurnal variation in temperature.
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? a) "Phagocytosis is the dynamic and energy-directed process where cells migrate, directed by chemoattractants." b) "The process of margination ensures that cells will follow the cytokine gradient." c) "The process of chemotaxis is the process where cells wander through the tissue guided by secreted chemoattractants." d) "Tissues have an abundance of inflammatory cells that are constantly migrating and just waiting for tissue injury."
"The process of chemotaxis is the process where cells wander through the tissue guided by secreted chemoattractants." Chemotaxis is the dynamic and energy-directed process of directed cell migration. Once leukocytes exit the capillary, they wander through the tissue guided by a gradient of secreted chemoattractant, bacterial and cellular debris, and protein fragments generated from activation of the complement system. -Phagocytosis is the engulfment of foreign or infective material. -Margination is the first step of the cellular stage and is a separate process from chemotaxis, which is the third step in the cellular response. -Tissues do not store inflammatory cells.
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. a) 14,000 to 20,000 cells/μL b) 4000 to 10,000 cells/μL c) 1000 to 3000 cells/μL d) 1500 to 20,000 cells/μL
4000 to 10,000 cells/μL A normal value of white blood cells would be 4000 to 10,000 cells/μL. In acute inflammatory conditions, the white blood cell count commonly increases from 15,000 to 20,000 cells/μL. The other results are abnormal.
A nurse is providing care for several clients on a neurologic unit of a hospital. With which client is the nurse justified in predicting a problem with thermoregulation?
66-year-old man with damage to his hypothalamus secondary to a cerebral vascular accident. The hypothalamus is involved in the sensation and regulation of body temperature. Syphilis, a T8 fracture, and damage to the cerebellum would be unlikely to manifest by difficulties with thermoregulation.
A nurse is providing care for several clients on a neurologic unit of a hospital. With which client is the nurse justified in predicting a problem with thermoregulation? a) 66-year-old man with damage to his hypothalamus secondary to a cerebral vascular accident. b) 22-year-old man with damage to his cerebellum secondary to a motorcycle accident. c) 68-year-old man with end-stage neurosyphilis. d) 45-year-old woman with a T8 fracture secondary to a diving accident.
66-year-old man with damage to his hypothalamus secondary to a cerebral vascular accident. The hypothalamus is involved in the sensation and regulation of body temperature. Syphilis, a T8 fracture, and damage to the cerebellum would be unlikely to manifest by difficulties with thermoregulation.
Which temperature readings indicate to the nurse that the clients have fever? Select all that apply. a) 35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) b) 19-year-old with oral reading of 38.4ºC (101.1ºF) c) 3-day-old with rectal reading of 38ºC (100.4ºF) d) 2-year-old with axillary reading of 35.8ºC (96.4ºF) e) 77-year-old with tympanic reading of 36.3ºC (97.3ºF)
• 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 core body temperature reading can be obtained from the esophagus, pulmonary artery catheter, a urinary catheter probe, or the rectum. For rapidly fluctuating temperatures, the pulmonary artery is most accurate. An oral temperature is generally lower than core by about 0.5ºC (1ºF). Axillary temperatures are approximately 0.5ºC (1ºF) lower than oral. A fever is temperature elevation above the body's normal set point which is usually between 36ºC (97ºF) and 37.5ºC (99.5ºF).
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) A 45 year old female with a T8 fracture secondary to a diving accident. b) A 22 year old male with damage to his cerebellum secondary to a motorcycle accident. c) A 68 year old male with end stage neurosyphilis. d) A 66 year old male with damage to his thalamus secondary to a cerebral vascular accident.
A 66 year old male with damage to his thalamus secondary to a cerebral vascular accident. The thalamus is involved in the sensation and regulation of body temperature. Syphilis, a T8 fracture and damage to the cerebellum would be unlikely to manifest by difficulties with thermoregulation.
A client presents with an oral temperature of 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) A severe bacterial infection b) A localized fungal infection c) A mild parasitic infection d) A mild viral infection
A severe bacterial infection Fever and painful, palpable lymph nodes are nonspecific inflammatory conditions; -leukocytosis is also common but is a particular hallmark of bacterial infection. -Neutrophilia also indicates a bacterial infection, -whereas increased levels of other leukocytes would indicate other etiologies. -The shift to the left---the presence of many immature neutrophils---indicates that the infection is severe, because the demand for neutrophils exceeds the supply of mature cells.
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) A severe fungal infection b) A severe bacterial infection c) A mild viral infection d) A mild parasitic infection
A severe bacterial infection Fever and painful, palpable lymph nodes are nonspecific inflammatory conditions; leukocytosis is also common but is a particular hallmark of bacterial infection. Neutrophilia also indicates a bacterial infection, whereas increased levels of other leukocytes would indicate other etiologies. The shift to the left--the presence of many immature neutrophils--indicates that the infection is severe, because the demand for neutrophils exceeds the supply of mature cells.
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? a) An older adult is often insensitive to exogenous pyrogens. b) An older adult is sometimes incapable of vasodilation. c) An older adult's hypothalamus has diminished thermoregulatory ability. d) Infections manifest by cognitive changes in older adults.
An older adult's hypothalamus has diminished thermoregulatory ability. The hypothalamus in older adults is often less capable of thermoregulation than in younger clients. -There are sometimes alterations in the release of endogenous pyrogens and deficits in vasoconstriction. -While infections do often manifest with cognitive changes in older adults, this does not explain why fever is precluded.
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? a) An older adult is often insensitive to exogenous pyrogens. b) Infections manifest by cognitive changes in older adults. c) An older adult's hypothalamus has diminished thermoregulatory ability. d) An older adult is sometimes incapable of vasodilation.
An older adult's hypothalamus has diminished thermoregulatory ability. The hypothalamus in older adults is often less capable of thermoregulation than in younger clients. There are sometimes alterations in the release of endogenous pyrogens and deficits in vasoconstriction. While infections do often manifest with cognitive changes in older adults, this does not explain why fever is precluded.
A patient has a splinter. The nurse expects a granulomatous inflammatory response. What does this involve? a) Macrophages attacking the splinter in order to dissolve it b) Connective tissue encapsulating and isolating the splinter c) Normal inflammatory mechanisms acting on the splinter d) Splinter being digested and dissolved
Connective tissue encapsulating and isolating the splinter Granulomatous inflammatory response to a splinter would involve the connective tissue encapsulating and isolating it for removal. Each of the other options are part of the normal inflammatory response, and would not apply in this situation.
The loss of heat from the body through the circulation of air currents is known as which of the following? a) Radiation b) Convection c) Evaporation d) Conduction
Convection Convection refers to heat transfer through the circulation of air currents, while - radiation is the transfer of heat through air or a vacuum. -Conduction is the direct transfer of heat from one molecule to another, and -evaporation involves the use of body heat to convert water on the skin to water vapor.
An older adult's dysfunctional temperature regulator function places the client at greatest risk for: a) Delayed initiation of appropriate treatment b) Acute renal failure c) Acute dementia d) Misdiagnosis of pathology
Delayed initiation of appropriate treatment The elderly often have a lower baseline temperature (36.4°C [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. The absence of fever may delay diagnosis and initiation of antimicrobial treatment. Absence of fever does not result in misdiagnosis. While the remaining options may occur, they are not the greatest risks for injury.
A nurse's hand-off reports states that the patient has pyrexia. The nurse plans care for the patient with which of the following events? a) Fever b) Rash c) Wound d) Incontinence
Fever When a patient is documented to have pyrexia, the nurse should plan care for a patient with a fever.
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? a) White blood cell migrate the site of the client's wound b) Scar tissue is synthesized and becomes visible at the wound site c) Blood clots form at the wound site to prevent bleeding d) Fibroblasts secrete the cells necessary for wound healing
Fibroblasts secrete the cells necessary for wound healing The primary processes during the proliferative phase focus on the building of new tissue to fill the wound space. The key cell during this phase is the fibroblast, a connective tissue cell that synthesizes and secretes the collagen, proteoglycans, and glycoproteins needed for wound healing. White cell migration and clot formation take place during the inflammatory phase. Scar formation occurs during remodelling.
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? a) Cachexic and Asian b) HIV positive and homeless c) Receiving intravenous normal saline with 20 mEq KCl d) Malnourished, hypomagnesemic, and hypocalcemic
HIV positive and homeless FUO is associated with HIV. The other aspects of the client's circumstances are not noted to correlate with FUO.
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? a) HIV positive and homeless b) Cachexic and Asian c) Receiving intravenous normal saline with 20 mEq KCl d) Malnourished, hypomagnesemic, and hypocalcemic
HIV positive and homeless FUO is associated with HIV. The other aspects of the client's circumstances are not noted to correlate with FUO.
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) Blood pressure b) Respiratory rate c) Heart rate d) White blood cell count
Heart rate 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 with environmental allergies is experiencing respiratory inflammation. Which mediator causes vasodilation during the vascular stage of the inflammatory response? a) Histamine b) Memory T cells c) Leukotrienes d) Adhesion molecules
Histamine Histamine is a key mediator in the inflammatory system and one that induces vasodilation during the vascular stage. Adhesion molecules, memory T cells, and leukotrienes do not participate in the process of vasodilation during the vascular stage.
What is the most common cause of drug fever? a) Serotonin syndrome b) Impaired peripheral heat dissipation by atropine c) Hypersensitivity reaction to medication d) Increased heat production from PTU
Hypersensitivity reaction to medication The most common cause of drug fever is a hypersensitivity reaction. Drug fever can also be caused by the antithyroid medication propylthiouracil (PTU), atropine and anticholinergic medications, antipsychotic agents, tricyclic antidepressants, cocaine, and amphetamines. -The agitation, hyperthermia, and hyperactivity of serotonin syndrome occur with overdose of serotonin reuptake inhibitors.
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 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.
The nurse evaluating the bloodwork results of a client with an infected leg ulcer. The white blood cell count is 18,000 cells/uL. The nures inteprets thsi as: a) Leukocytosis b) Lymphadenitis c) Nuetropenia d) Lymphacytosis
Leukocytosis A white blood cell count of 18,000 cells/uL is indicative of an elevated white blood cell count or leukocytosis (normal range is 4000-10,000 cells/uL). This would be an expected finding in a client with an infected leg ulcer. -An increase in lymphocityes is lymphacytosis and neutropenia is a decrease in neutrophil's. Lymphadenitis is an inflammation in the lymph nodes.
A client was skating on the lake when the ice broke and he was submerged for 15 minutes. When rescuers were able to retrieve him from the water, his core temperature was 31° C (87.8°F). Into which classification does this temperature fit? a) Lethally hypothermic b) Mildly hypothermic c) Moderately hypothermic d) Severely hypothermic
Moderately hypothermic Core body temperatures in the range of 32°C to 35°C (90°F to 95°F) are considered mildly hypothermic; 28°C to 32°C -(82.4°F to 90°F), moderately hypothermic; and -less than 28°C (82.4°F), severely hypothermic. -Lethally hypothermic is not a classification, but if hypothermia goes untreated, it is possible to freeze to death.
A patient 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 patient's physician has ordered a complete blood count and white cell differential. Which of the following blood components would the physician most likely anticipate to be elevated? a) Platelets b) Neutrophils c) Basophils d) Eosinophils
Neutrophils Increased neutrophils are associated with inflammation in general and bacterial infections in particular. -Platelets play a role in inflammation but their levels would not rise to the same extent as would neutrophils. -Eosinophils are not strongly associated with bacterial infection and -basophils would not increase to the same degree as neutrophils.
A patient 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 patient's physician has ordered a complete blood count and white cell differential. Which of the following blood components would the physician most likely anticipate to be elevated?
Neutrophils Increased neutrophils are associated with inflammation in general and bacterial infections in particular. Platelets play a role in inflammation but their levels would not rise to the same extent as would neutrophils. Eosinophils are not strongly associated with bacterial infection and basophils would not increase to the same degree as neutrophils.
A client is said to be in the chill stage of the fever process when the nurse does which of the following? a) Observes the client is sweating b) Observes piloerection on the skin c) Determines the client will benefit from a cool sponge bath d) Administers an antipyretic medication
Observes piloerection on the skin During the second stage or chill, there is the uncomfortable sensation of being chilled and the onset of generalized shaking (rigors). -Vasoconstriction and piloerection usually precede the onset of shivering. At this point, the skin is pale and covered with goose flesh. -Sweating is an indication of the third stage or flushing. -The other options are not descriptive of stages but rather interventions.
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) Increased bacterial infection c) Redness d) Decreased sensation at the site
Redness 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 nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for: a) Parasthesis, redness, and coolness b) Pain, pulselessness, and edema c) Rubor, swelling, and pain d) Cyanosis, heat, and swelling
Rubor, swelling, and pain 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.
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: a) Increase the room temperature by turning off the air conditioner and continue sponging the client with warmer water b) Administer an extra dose of aspirin c) Place a heated electric blanket on the client's bed d) Stop sponging the client and retake a set of vital signs
Stop sponging the client and retake a set of vital signs 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.
Which client manifestation indicates signs of drug fever? a) Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis b) Temperature reaches 38°C (100.4°F) for 3 days, pulse 106 beats/minute, purulent drainage c) Temperature reaches 39°C (102.2°F) following aerobic activity, pulse 125 beats/minute, sweating d) Temperature reaches 41°C (105.8°F) after a sauna, pulse 76 beats/minute, skin hot and dry
Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis Clients with drug fever often show signs of hypersensitivity such as joint pain, itching, rashes, muscle pains, and gastrointestinal distress. The fever has a diurnal pattern with the highest point in the afternoon or early evening. The clients in the other options are exhibiting signs of infection, heat exhaustion, and heatstroke.
The nurse assessing a client admitted with a diagnosis of "fever of unknown origin" notes that the temperature is elevated, but the heart rate is within normal range. What further assessment will the client require? a) V/Q scan for pulmonary emboli b) Thyroid scan for nodules c) Test for Legionnaire disease d) Sedimentation rate for RA
Test for Legionnaire disease Typically, the heart rate rises with an elevation of temperature. If the heart rate is more rapid than anticipated, it could be from hyperthyroidism or pulmonary emboli. A heart rate that is slower than expected could result from Legionnaire disease or drug fever. Further testing is needed to confirm the cause of the fever and determine proper treatment.
A client who is scheduled for orthopedic surgery has expressed concern about the risk of malignant hyperthermia. The nurse should reassure the client that the anesthesiologist will: a) administer antipyretics intravenously at the first sign of the problem. b) administer dantrolene 30 to 60 minutes before surgery to prevent the problem. c) intubate the client in order to prevent malignant hyperthermia d) carefully assess the client's genetic risk of the problem.
carefully assess the client's genetic risk of the problem. Family history is a significant factor when appraising a client's risk of malignant hyperthermia. Dantrolene is only administered if active treatment is needed. Antipyretics are ineffective. Intubation is necessary during surgery but does not prevent malignant hyperthermia.
Which clients are showing manifestations of infection? Select all that apply. a) A 50-year-old, temperature 36.2°C (97.3°F), heart rate 65 beats/min, muscle aches b) A 25-year-old, temperature 40°C (104°F), sweating, shivering, states generalized pain c) A 5-year-old, temperature 36.8°C (98.2°F), talkative, actively engaged in playing d) A 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis e) 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), • A 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis • A 75-year-old, temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue An older adult with an infection may have a minimal rise in temperature, but exhibit changes in mental status, weakness, fatigue, and weight loss. An infant younger than three months may have a relatively mild fever, but a serious infection. An adult with a high fever will exhibit sweating and chills. Aches and pains may occur with shivering and the infectious illness. - A client with a temperature within the normal range, exhibiting no other signs of change, is not considered to have an infection.
Which of the following lab results confirm the client has developed an acute-phase inflammatory response? Select all that apply. a) C-reactive protein (CRP) 10.0 mg/L (high). b) Leukocytes (WBC) 18.7 cells/μL (high). c) Fibrinogen level 1.5 g/L (normal). d) Erythrocyte sedimentation rate (ESR) 175 mm/h (high). e) Red blood cell count (RBC) 3.11 cells/μL (low).
• Erythrocyte sedimentation rate (ESR) 175 mm/h (high). • Leukocytes (WBC) 18.7 cells/μL (high). • C-reactive protein (CRP) 10.0 mg/L (high). During the acute-phase response, the liver dramatically increases the synthesis of acute-phase proteins such as fibrinogen, C-reactive protein (CRP), and serum amyloid A protein (SAA) that serve several different defense functions. -The synthesis of these proteins is stimulated by cytokines, especially TNF-α, IL-1 (for SAA), and IL-6 (for fibrinogen and CRP). -The accelerated erythrocyte sedimentation rate (ESR) that occurs in disease conditions is characterized by the systemic inflammatory response. -Leukocytosis, or the increase in white blood cells, is a frequent sign of an inflammatory response, especially those caused by bacterial infection. - In acute inflammatory conditions, the white blood cell count commonly increases from a normal value of 4000 to 10,000 cells/μL.
