Inflammation, the Inflammatory Response, and Fever
Which symptom indicates the next stage of a fever after a prodrome? a) A flush b) A chill c) Predrome d) Defervescence
b) A chill Explanation: 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.
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) White blood cell count b) Heart rate c) Respiratory rate d) Blood pressure
b) 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 patient's temperature readings are as follows: 99.6°F at 4 pm; 102°F at 8 pm; and 97.9°F at 12 am. The nurse's hand-off should include which of the following? a) Prodermal phase b) Intermittent fever c) Defervescence d) Remittent fever
b) Intermittent fever Explanation: The nurse's hand-off report should include the presence of intermittent fever—a temperature that returns to normal at least once every 24 hours.
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 66 year old male with damage to his thalamus secondary to a cerebral vascular accident. b) A 22 year old male with damage to his cerebellum secondary to a motorcycle accident. c) A 45 year old female with a T8 fracture secondary to a diving accident. d) A 68 year old male with end stage neurosyphilis
a) A 66 year old male with damage to his thalamus secondary to a cerebral vascular accident. Explanation: 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.
Inflammation can be either local or systemic. What are the most prominent systemic manifestations of inflammation? a) Fever, leukocytosis or leukopenia, and the acute phase response b) Fever, leukocytosis or leukopenia, and the transition phase response c) Widening pulse pressure, thrombocytopenia, and the recovery phase response d) Widening pulse pressure, thrombocytopenia, and the latent phase response
a) Fever, leukocytosis or leukopenia, and the acute phase response Explanation: The most prominent systemic manifestations of inflammation include the acute phase response, alterations in white blood cell count (leukocytosis or leukopenia), and fever. A widening pulse pressure is not indicative of systemic inflammation, and thrombocytopenia is a hematologic disorder, not an indication of systemic inflammation.
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) Fungus b) Pustule c) Ulceration d) Abscess
c) 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
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) 1500 to 20,000 cells/μL b) 1000 to 3000 cells/μL c) 14,000 to 20,000 cells/μL d) 4000 to 10,000 cells/μL
d) 4000 to 10,000 cells/μL Explanation: 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 client cuts herself with a sharp knife while cooking dinner. The client describes how the wound started bleeding and had a red appearance almost immediately. The nurse knows that in the vascular stage of acute inflammation, the vessels: a) Constrict as a result of "fight/flight" hormone release resulting in pale-colored skin b) Swell to the point of compromising circulation causing the limb to become cool to touch c) Bleed profusely until the body can compensate and start to send fibrinogen to the wound d) Vasodilate causing the area to become congested causing the red color and warmth
d) Vasodilate causing the area to become congested causing the red color and warmth Explanation: Vasodilation allows more blood and fluid into the area of injury, resulting in congestion, redness, and warmth. Vasodilation is quickly followed by increased permeability of the microvasculature. The loss of fluid results in an increased concentration of blood constituents (red blood cells, leukocytes, platelets, and clotting factors), stagnation of flow, and clotting of blood at the site of injury. This aids in limiting the spread of infectious microorganisms. The loss of plasma proteins increases fluid movement from the vascular compartment into the tissue space and producing the swelling, pain, and impaired function that are the cardinal signs of acute inflammation
A nurse's hand-off report states that a patient's temperature is 106.6°F. Which of the following may have caused the patient's temperature to elevate past 105.8°F? Select all that apply. a) Urinary tract infection b) Hyperthermic state c) Convulsions d) Systemic infection
• Convulsions • Hyperthermic state Explanation: Fevers that rise aboue 105.8°F are usually the result of superimposed activity such as convulsions, hyperthermic states, or direct impairment of the temperature control center.
Which statements are true regarding chronic inflammation? Select all that apply. a) It involves the presence of mononuclear cells like lymphocytes. b) The inflammatory agent is usually resistant to phagocytosis. c) The condition is self-limiting in nature. d) Granulocytes are generally observed at sites of chronic inflammation. e) It is usually a result of persistent irritants.
• It is usually a result of persistent irritants. • The inflammatory agent is usually resistant to phagocytosis. • It involves the presence of mononuclear cells like lymphocytes. Explanation: In contrast to acute inflammation, which is self-limiting, chronic inflammation is prolonged and usually is caused by persistent irritants, most of which are insoluble and resistant to phagocytosis and other inflammatory mechanisms. Chronic inflammation involves the presence of mononuclear cells (lymphocytes and macrophages) rather than granulocytes.
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) Palpable lymph nodes b) Diarrhea c) Edema d) Fever
d) 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.
A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as an: a) Decrease in eosinophils at the tissue injury site b) Increase in cell production c) Decrease in blood supply to the affected area d) Increase in circulating neutrophils
d) 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 is typically increased as part of the inflammatory process.
A patient diagnosed with bacterial pneumonia is admitted to the hospital. The nurse reviewing the patient's laboratory results notes an increase in the number of bands in the white blood cell count. Which of the following is the priority action of the nurse? a) Continuing to monitor the client's laboratory results; this is an expected finding in an acute infection b) Placing the client in contact isolation immediately c) Requesting a repeat blood draw to verify the findings d) Notifying the physician of the abnormal lab result
a) Continuing to monitor the client's laboratory results; this is an expected finding in an acute infection Explanation: Neutrophilia is an increase in immature neutrophils (bands) seen in the peripheral blood. It is most commonly seen in acute infections and tissue injuries that promote the accelerated release of neutrophils and their precursors into the circulation.
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
a) Flushed skin Explanation: 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 nurse instructing unlicensed personnel on temperature regulation includes that core body and skin temperatures are sensed by which of the following parts of the brain? a) Hypothalmus b) Medulla c) Cerebellum d) Cerebral cortex
a) Hypothalmus explanation: Core body and skin temperatures are sensed and integrated by the thermoregulatory regions in the hypothalmus
A patient is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for which of the following? a) Temperature b) Urinary output c) Respirations d) Hypothermia
a) Temperature Explanation: Common clinical manifestations of fever include anorexia, myalgia, arthralgia, headaches, and fatigue; thus, the nurse should assess the patient's temperature
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) Test for Legionnaire disease b) V/Q scan for pulmonary emboli c) Thyroid scan for nodules d) Sedimentation rate for RA
a) Test for Legionnaire disease Explanation: 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 nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the patient's temperature on admission and finds that it is 96.6°F. Which of the following describes how the nurse should interpret the finding? a) The patient may be exhibiting a blunted or absent febrile response. b) The patient's temperature is normal so the patient does not have an infection. c) The patient is exhibiting a normal febrile response to a urinary tract infection. d) The patient's absent febrile response indicates absence of an infection.
a) The patient may be exhibiting a blunted or absent febrile response Explanation: The nurse should interpret the finding as a blunted or absence febrile response to the infection. It has been suggested that as many as 30% of older adults with serious infections present with absent or blunted febrile response, and this may delay diagnosis and initiation of antimicrobial treatment
A child age 33 days is presented to the emergency department of a hospital by her parents following a two day fever. Her temperature is 38°C (100.4°F) tympanically. Which of the following diagnostic tests is most clearly indicated? a) Urine for culture and sensitivity. b) Electrolytes, blood urea nitrogen (BUN) and creatinine levels. c) Abdominal ultrasound. d) Computed tomography (CT) of the head
a) Urine for culture and sensitivity. Explanation: Infants with a fever are at risk of urinary tract infections, which would be diagnosed through a urine test for culture and sensitivity. Electrolytes, BUN and creatinine, CT head and abdominal ultrasound are not as closely associated with differential diagnosis of the child's fever.
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's hypothalamus has diminished thermoregulatory ability. c) An older adult is sometimes incapable of vasodilation. d) Infections manifest by cognitive changes in older adults.
b) An older adult's hypothalamus has diminished thermoregulatory ability. Explanation: 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 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) Prodrome b) Chill c) Flush d) Defervescence
b) Chill Explanation: 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.
An older adult's dysfunctional temperature regulator function places the client at greatest risk for: a) Acute dementia b) Delayed initiation of appropriate treatment c) Acute renal failure d) Misdiagnosis of pathology
b) Delayed initiation of appropriate treatment Explanation: 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
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 containing white blood cells, protein, and tissue debris c) Exudate that is watery fluid, low in protein d) Exudate that resulted from leakage of red cells
b) 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
What is the most common cause of drug fever? a) Increased heat production from PTU b) Hypersensitivity reaction to medication c) Impaired peripheral heat dissipation by atropine d) Serotonin syndrome
b) Hypersensitivity reaction to medication Explanation: 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 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) Systemic b) Neurogenic c) Exdogenous d) Intrinsic
b) Neurogenic Explanation: 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.
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) Increase intravenous fluid rate b) Notify the physician c) Document the temperature d) Offer the client a cold drink
b) Notify the physician Explanation: 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 client is said to be in the chill stage of the fever process when the nurse does which of the following? a) Administers an antipyretic medication b) Observes piloerection on the skin c) Observes the client is sweating d) Determines the client will benefit from a cool sponge bath
b) Observes piloerection on the skin Explanation: 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.
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) Poorly controlled blood sugars with small blood vessel disease. c) Chronic obstructive pulmonary disease. d) Congenital heart defects and anemia.
b) Poorly controlled blood sugars with small blood vessel disease. Explanation: Diabetes mellitus is strongly associated with impaired wound healing. The other noted pathologies are less causative of deficiencies in the healing process.
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? a) Decrease heart rate b) Reduce oxygen demand c) Prevent hyperkalemia d) Promote general comfort
b) Reduce oxygen demand Explanation: Fever can be beneficial under certain circumstances. Relatively small increases in fever can stimulate immune response by T lymphocyte proliferation. The growth of many microbes is inhibited at temperatures in the fever range. Fever can cause discomfort such as headache and body aches. Fever above 42.2ºC (108ºF) can cause cell damage and life-threatening acidosis, hypoxia, and hyperkalemia. Older adults with cardiac or pulmonary conditions who develop fever are at risk of hypoxia because each degree of temperature elevation in Celsius raises the basal metabolic rate by about 7%. In a client with an average body temperature of about 37ºC (98.6ºF), the rise to 38.3ºC would increase the metabolic demand by more than 7%. A client with longstanding COPD would have difficulty maintaining adequate oxygen saturation
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) Administer an extra dose of aspirin b) Stop sponging the client and retake a set of vital signs c) Increase the room temperature by turning off the air conditioner and continue sponging the client with warmer water d) Place a heated electric blanket on the client's bed
b) Stop sponging the client and retake a set of vital signs Explanation: 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.
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 mild viral infection b) A mild parasitic infection c) A severe bacterial infection d) A severe fungal infection
c) A severe bacterial infection Explanation: 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 deficiency in which of the following would result in an inhibition of the inflammatory response? a) Helper T cells b) B cells c) Histamine d) Vitamin K
c) Histamine Explanation: Histamine is a key mediator in the inflammatory system, unlike helper T cells, B cells, or vitamin K
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) Basophils b) Platelets c) Neutrophils d) Eosinophils
c) Neutrophils Explanation: 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 normal response to fever is an elevated heart rate. A client with a fever who is not exhibiting an elevated heart rate would indicate to the nurse that the cause of the fever might be which of the following? a) Hyperthyroidism b) Flu c) Pulmonary emboli d) Legionnaires disease
d) Legionnaires disease Explanation: The observation that a rise in temperature is not accompanied by the anticipated change in heart rate can provide useful information about the cause of the fever. For example, a heart rate that is slower than would be anticipated can occur with Legionnaire disease and drug fever, and a heart rate that is more rapid than anticipated can be symptomatic of hyperthyroidism and pulmonary emboli
A client asks why his temperature is always below 98.6°F. The nurse responds: a) The best way to bring your body temperature up to normal is to live in a warmer climate. b) Some people maintain a core body temperature of 41°C and that is normal for them. c) A person's highest point of core temperature is usually first thing in the morning. d) Normal core temperature varies between individuals within the range of 97.0°F to 99.5°F.
d) Normal core temperature varies between individuals within the range of 97.0°F to 99.5°F. Explanation: 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.