Mastery quiz questions Ch.3

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.

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?

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.

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

Which of the following can the nurse tell a patient about antipyretic drugs during fever?

Antipyretics help 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 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?

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

Which of the following patients is most likely to have impairments to the wound healing process? A patient with:

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.

A nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for:

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

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 -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.

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.

• Fatigue • Decreased mental status • Change in fuctional capacity -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 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.

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 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 -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.

The loss of heat from the body through the circulation of air currents is known as which of the following?

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.

A nurse who is providing a staff development in-service determines that the participants understand the information when they state that which of the following aids heat conservation by reducing surface area for heat loss?

Erection of pilomotor muscles -The nurse determines that the participants understand the information when they identify that erection of pilomotor muscles aids heat conservation by reducing surface area for heat loss.

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 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?

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 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?

Legionnaires disease -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

The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation?

Loss of function -These signs are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). In the second century ad, the Greek physician Galen added a fifth cardinal sign, functio laesa (loss of function). Altered level of consciousness is not a cardinal sign of inflammation. Sepsis and fever are systemic signs of infection.

The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading?

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.

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 -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 a watery fluid leaking from a site of inflammation. The nurse would document this type of exudate as:

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.

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:

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.

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:

Vasodilate causing the area to become congested causing the red color and warmth -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 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. -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 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?

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 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 this as:

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 nuetriphils. Lymphadenitis is an inflammation in the lymph nodes.

The route considered the most accurate to measure a core body temperature is which of the following?

Rectal

Which of the following patients are at increased risk for hyperthermia? Select all that apply.

• Quadriplegic attending an outdoor summer event • Patient with heart disease in an nonairconditioned vehicle • Patient with schizophrenia taking haloperidol -Thermoregulation that is controlled by the hypothalamus is impaired in patients with spinal cord injuries higher than T6 because they are not able to receive signals to vasodilate or sweat below the level of injury. Circulation of blood to the body surface helps to cool the body. Individuals with heart disease have reduced capacity to dissipate heat. Medications that predispose clients to hyperthermia include diuretics, neuroleptics, and anticholinergics.