AQ chp 6

When a client's complement system is stimulated, which processes will be activated? Select all that apply. Opsonization Initiation of collectins Degranulation of mast cells Activation of the normal microbiome Lysis of cells through membrane disruption

Activation of complement can cause cell lysis, mast cell degranulation, and opsonization. The lung produces and secretes a family of glycoproteins, collectins, to fight infection. A spectrum of nonpathogenic microorganisms, collectively called the normal microbiome, resides on the body's surfaces.

The nurse is reviewing the laboratory reports of four clients who each underwent an appendectomy for appendicitis. Which client is at the highest immediate risk for wound dehiscence? A. Increased in white blood cell count B. Decrease in blood glucose levels C. Decrease in estrogen levels D. Increase in thyroid stimulation hormone levels

An increase in a client's white blood cell count is an indication of infection. Wound dehiscence is associated with infection approximately half of the time. A decrease in blood glucose levels indicates that Client B has hypoglycemia. Hypoglycemia may impair wound healing, but does not immediately increase the risk of dehiscence. A decrease in estrogen levels in Client C does not impair wound healing and does not increase the risk of wound dehiscence. In Client D, hyperthyroidism increases metabolic needs and may interrupt healing, but does not immediately increase the risk of wound dehiscence.

A client's laboratory results indicate an increase in tumor necrosis factor α, interleukin 6, and prostaglandin. Which condition does the nurse expect to find in the client? Cachexia Hemophilia Chemotaxis Gram-positive bacterial infection

An increase in tumor necrosis factor α causes muscular wasting and results in cachexia. Chemotaxis, or the attraction of leukocytes to the site of infection, is an effect of interleukin 1, not interleukin 6. Gram-positive bacterial infection has no relationship to TNF α or interleukin 6.

A client has a severe inflammatory response. Which complement factor is considered a potent anaphylatoxin? C7 C9 C3a C5b

C3a and C4a are anaphylatoxins, and they can induce rapid degranulation of mast cells. C5a is a chemotactic factor as well as an anaphylatoxin. C5b-C9, membrane attack complex, causes pores to form in the bacterial membrane through which water may enter the cell, causing the cell to die.

How should the nurse describe the role of chemotaxis in inflammation to a coworker? It releases histamine at the site of injury. It leads to vascular changes at the site of injury. It initiates the clotting cascade at the site of injury. It causes migration of leukocytes to the site of injury.

Chemotaxis is the directed migration of leukocytes to the site of injury. Degranulation of mast cells is responsible for the release of histamine at the site of injury. The clotting cascade is initiated by extrinsic or intrinsic pathways. Chemotaxis is not involved in the clotting cascade. Vascular changes of inflammation are the result of the complex interaction of several cellular and chemical processes at the site of injury, mainly from histamine.

While reviewing the laboratory reports of a newborn, the nurse finds that the newborn has α 1-antitrypsin deficiency. Which test should be prescribed later in the child's life to determine effects? Renal functioning test Thyroid functioning test Cardiac functioning test Pulmonary functioning test

Deficiency of α 1-antitrypsin results in chronic lung damage and emphysema due to inflammation. Performing pulmonary function testing will help provide effective treatment. α 1-antitrypsin is secreted by the liver and not by the kidneys or thyroid gland. Therefore, renal and thyroid functioning tests are not required for the newborn. Deficiency of α 1-antitrypsin does not impair cardiac functioning.

During wound healing a client develops contracture of scar tissue. Which problems should the nurse monitor for in this client? Select all that apply. Dehiscence Tissue proliferation Impaired blood flow Granuloma formation Limited movement at joints

Excessive wound contraction at a joint can inhibit movement, and internal contractures can reduce blood flow to an area. Dehiscence is the opening of a sutured wound. Tissue proliferation is involved in healthy wound healing. Granuloma formation occurs with chronic inflammation and is not associated with wound contracture.

A client is in phase II of wound healing. Which cells produce collagen during tissue healing? Mast cells Fibroblasts Macrophages Endothelial cells

Fibroblasts are important cells during healing because they secrete collagen and other connective tissue proteins. Mast cells do not produce collagen but release histamine. Endothelial cells regulate circulating components of the inflammatory system and maintain normal blood flow by preventing spontaneous activation of platelets and members of the clotting system. Macrophages stimulate the cells that produce collagen, but they do not produce collagen themselves.

After reviewing the genetic reports of a client, the nurse suspects that the client has hereditary angioedema. Which finding supports the nurse's conclusion? Decrease in clotting factors Increase in tumor necrosis factor Decrease in prostaglandin levels Increase in plasma protein system

Genetic effects in C1 esterase inhibitor result in hereditary angioedema, which is associated with an increase in plasma protein system, such as excessive production of bradykinin. Decrease in clotting factors occurs in clients with hemophilia. Prostaglandins increase vascular permeability, but it is excessive production of bradykinin that is responsible for the increased vascular permeability in hereditary angioedema. Increase in tumor necrosis factor increases risk of muscle wasting syndrome.

A nurse is teaching about examples of granulocytes. Which cellular class should the nurse include? Basophils Monocytes T lymphocytes Natural killer cells

Granulocytes are the most common leukocytes and are classified by the type of stains needed to visualize enzyme-containing granules in their cytoplasm: basophils, eosinophils, and neutrophils. Monocytes are precursors of macrophages that are found in the tissue. Various forms of lymphocytes participate in the innate immune response (natural killer [NK] cells) and the acquired immune response (B and T cells).

Which information indicates the nurse has a correct understanding of a cytokine that has some anti-inflammatory effects? Interleukin-1 (IL-1) Interleukin-6 (IL-6) Interleukin-10 (IL-10) Tumor necrosis factor alpha (TNF-alpha)

IL-10 has some anti-inflammatory effects, leading to down-regulation of both inflammatory and acquired immune responses. IL-1, IL-6, and TNF-alpha are proinflammatory

A client has a chronic infection of Listeria that the body cannot fight. Which pathophysiologic process should the nurse monitor for in this client Granuloma Regeneration Lectin pathway Compensatory hyperplasia

If macrophages are unable to protect the host from tissue damage, the body attempts to wall off and isolate the infected area, thus forming a granuloma; this often occurs with chronic Listeria infection (listeriosis). Repaired tissues may be close to normal if damage is minor, no complications occur, and destroyed tissues are capable of regeneration. Only epithelial, hepatic, and bone marrow cells are capable of the complete mitotic regeneration of the normal tissue, known as compensatory hyperplasia. The Lectin pathway is one method to activate the complement system.

Which process in a client with a severe viral infection supports the nurse's suspicion that the client has risk of cachexia? Decrease in Hageman factor Decrease in white blood cell count Increase in serum creatinine levels Increase in tumor necrosis factor-alpha

Increase in tumor necrosis factor-alpha causes cachexia and intravascular thrombosis. Hageman is a clotting factor; a decrease in Hageman factor increases the risk of bleeding. The white blood cell count increases in the client with an infection. High serum creatinine levels increase the risk of renal impairment.

A client receiving antibiotics is experiencing perineal discomfort when urinating. Which microorganism should the nurse suspect is causing this client's problem? Lactobacillus Salmonella typhi Clostridium difficile Pseudomonas aeruginosa

Lactobacillus is a major vaginal flora commonly found in healthy women. It helps to produce hydrogen peroxide, lactic acid, and other molecules that help to prevent vaginal infection and urinary tract Infection caused by bacteria and yeast. Lactobacilli colonization diminishes upon prolonged use of antibiotics, which increases the risk of urologic and vaginal Infection, such as vaginosis. Salmonella typhi leads to typhoid fever. Clostridium difficile causes infection of the colon, pseudomembranous colitis. Pseudomonas aeruginosa is a normal flora on the skin. It produces toxin, which protects the skin against staphylococcal Infection.

A client lies on a concrete floor for 9 hours after a heroin overdose and develops a deep pressure ulcer on the sacrum. How will the nurse expect this wound to heal? Remodeling Primary intention Classical pathway Secondary intention

A pressure ulcer heals by secondary intention because of extensive loss of tissue. The wound edges cannot be approximated and result in extensive scar formation. Remodeling is a stage of tissue healing and does not describe how the pressure ulcer will heal. The classical pathway is one of three ways the complement system can be activated. A wound with minimal tissue loss and approximation of wound edges will be able to heal by primary intention.

The nurse is caring for a client with swelling and pain at the site of a wound. Which other physiological changes does the nurse expect to find? Select all that apply. Increased redness Increased blood flow Decreased local temperature Decreased hemoglobin levels Increased blood glucose levels

Presence of swelling and pain at the site of the wound indicates that the client has inflammation at the wound site. Inflammation causes vasodilatation, which causes the site to appear red from increased blood flow. Inflammation does not impair hemoglobin formation. Inflammation is associated with an increase in temperature at the site of inflammation. Inflammation does not impair pancreatic functioning and does not cause hyperglycemia.

Which complication will the nurse monitor for in a client who has been prescribed long-term antibiotic therapy? Increased risk of bleeding Increased risk of hypertension Increased risk of hypoglycemia Increased risk of Candida albicans infection

Prolonged treatment with antibiotics alters the normal intestinal microbiome and causes overgrowth of yeast such as Candida albicans. Therefore, the nurse should plan care to address the potential for a Candida albicans infection. Antibiotics do not impair clotting, nor do they cause bleeding. Antibiotics do not cause vasoconstriction or hypertension. Antibiotics do not impair insulin production or cause hypoglycemia.

A client with an intestinal infection is receiving prolonged treatment with antibiotics. Which deficiencies are likely to occur in the client? Select all that apply. Vitamin K Bacteriocins Candida albicans Clostridium difficile Opportunistic microorganisms

Prolonged treatment with antibiotics inhibits the intestinal microbiome, which synthesizes vitamin K, thereby potentially resulting in vitamin K deficiency. Prolonged antibiotic use also inhibits the production of proteins called bacteriocins that inhibit pathogens. Opportunistic organisms are likely to increase in number when a client has been on antibiotics because these organisms thrive when the innate and acquired immune systems are compromised. Prolonged antibiotic use can cause an overgrowth of Candida albicans and Clostridium difficile because the normal gut flora that control these microorganisms may be affected by the antibiotics.

While reviewing the medication history of a client, the nurse finds that the client is receiving long-term therapy with broad-spectrum antibiotics. Which complications does the nurse expect to find? Vaginosis Sun sensitivity Hyponatremia Lactic acidosis Pseudomembranous colitis

Prolonged treatment with broad-spectrum antibiotics diminishes the growth of normal vaginal and intestinal flora and increases the risk of vaginosis and pseudomembranous colitis. Long-term antibiotic use diminishes Lactobacillus colonization and leads to reduced production of lactic acid in the vagina. Prolonged treatment with broad-spectrum antibiotics does not cause hyponatremia or sun sensitivity.

When should the nurse chart that the client has purulent exudate? When reddish exudate, containing numerous red blood cells, occurs When whitish-yellow exudate, containing many leukocytes, occurs When watery exudate, containing few cells and not much protein, occurs When thick, clotted exudate, containing many plasma proteins, occurs

Purulent exudate (pus) is whitish-yellow, because it contains many white blood cells and pus. Hemorrhagic exudate is reddish, because it contains numerous red blood cells. Fibrinous exudate is thick and sticky, because it contains large amounts of fibrin. Serous exudate is watery, because it contains few cells and not much protein.

A nurse is caring for an adult who had surgery three days ago. Which assessment finding does the nurse recognize as abnormal and needing immediate attention? 3 on a pain scale of 10 Skin next to incision slightly edematous Pulse: 80 beats per minute, regular rhythm Small amount of purulent exudate visible at distal end of incision

Purulent exudate is an indicator of bacterial infection or walled-off lesions (cysts or abscesses), which needs immediate attention. 3 on a pain scale of 10 is expected in the first few days after an incision. Pulse is 80, which is normal. Slight edema and serous exudate are normal manifestations of mild inflammation, which is expected in the first few days after a surgical incision.

A client has an infection and the neutrophil level is elevated. Which function are the neutrophils providing for the client? Phagocytosis Antibody production Antigen presentation Immunologic memory

The major function of neutrophils is phagocytosis. Neutrophils do not produce antibodies. Antigen-presenting cells are macrophages and dendritic cells. Memory cells, not neutrophils, provide immunologic memory.

A client sprains the left ankle. Before assessing the client for the classic signs of inflammation, the nurse remembers which cell type is responsible for the changes? Mast cells Fibroblasts Neutrophils Macrophages

The mast cell is probably the most important cellular activator of the inflammatory response. At a site of tissue damage, histamine is released from mast cells and produces many of the classic signs of inflammation. Fibroblasts are necessary for wound healing. While neutrophils and macrophages are involved in inflammation, they are not responsible for the classic signs of inflammation.

Which information from the staff indicates effective teaching by the nurse for substances that act as opsonins? Fibrin Antigens Histamine Complement proteins

The most potent opsonin produced by the complement system (plasma proteins) is C3b; antibodies are also efficient. Antibodies are made against antigens on the surface of bacteria and are highly specific to that particular microorganism; antigens are molecules against which the immune system reacts. Fibrin is the end product of the clotting cascade and can trap circulating cells, but it does not act as an opsonin. Histamine is an inflammatory mediator but does not act as an opsonin.

A nurse observes warmth and redness of the client's skin during inflammation. Which processes causes these changes? Select all that apply. Vasodilation Phagocytosis Vasoconstriction Neutrophil chemotaxis Increased vascular permeability

Vascular changes that develop during the inflammatory process, such as vasodilation and increased capillary permeability, increase blood flow to injured tissues, causing warmth and redness. Phagocytosis removes microorganisms and tissue debris but does not cause warmth and redness. Phagocytosis contributes to the formation of exudate and pus during inflammation. The initial vasoconstriction reduces blood loss but does not cause the warmth and redness. Neutrophil chemotaxis is part of the process of inflammation but does not cause redness and warmth at the site of injury.

A client has a low pH of urine and stomach contents. How should the nurse interpret these findings? The first line of defense is working. The third line of defense is working. The fourth line of defense is working. The second line of defense is working.

pH is a barrier against infection and is considered a first line of defense. The second line of defense is inflammation. The third line of defense is adaptive immunity. There is no fourth line of defense.

A client with arthritis has severe inflammation in the knee, along with fever and anxiety. During the follow-up visit, the nurse finds that the client still has inflammation and swelling in the knee, but the fever and anxiety have subsided. Which medication does the nurse anticipate finding in the client's prescription? Aspirin Diazepam (Valium) Acetaminophen (Tylenol) Hydromorphone (Dilaudid)

Aspirin is a non-steroidal anti-inflammatory medication that reduces prostaglandin synthesis and reduces inflammation. Therefore, prescribing aspirin will be beneficial for the client since the client still has inflammation and swelling in the knee. Diazepam (Valium) is an anxiolytic medication that helps to reduce the symptoms of anxiety; it is not needed since the anxiety has subsided. Acetaminophen (Tylenol) is an analgesic and a fever reducer, but is not a non-steroidal anti-inflammatory medication, so it would not be beneficial since the fever has subsided. Hydromorphone (Dilaudid) is an opioid analgesic, but does not have anti-inflammatory properties to help with the swelling and inflammation that are still present.

Which information indicates the nurse has a correct understanding of bradykinin? Bradykinin can induce pain. Bradykinin activates the clotting system. Bradykinin increases vascular permeability. Bradykinin causes smooth muscle cell contraction. Bradykinin causes vasoconstriction of blood vessels.

Bradykinin causes dilation of blood vessels, acts with prostaglandins to induce pain, causes smooth muscle cell contraction, and increases vascular permeability. Bradykinin does not activate the clotting system, but both the kinin and clotting systems can be activated by factor XIIa (prekallikrein).

Which information indicates the nurse has a good understanding of chronic inflammation? Chronic inflammation causes persistent bacterial infection, with local pockets of pus. Chronic inflammation causes differentiation of macrophages into epithelioid and giant cells. Chronic inflammation is an autoimmune process that is uncontrolled and causes repeated tissue damage. Chronic inflammation is a large number of neutrophils in an area of active inflammation that has not yet healed.

Chronic inflammation is characterized by dense infiltration of lymphocytes and macrophages. The macrophages differentiate into epithelioid and giant cells that form the center of the granuloma. Chronic inflammation can occur without autoimmune processes. Large numbers of neutrophils accumulate with acute inflammation. Chronic inflammation can occur without bacterial infection or local pockets of pus.

The nurse caring for a client with poorly controlled diabetes mellitus gives priority to assessment for postoperative wound infection. What is the best rationale for the nurse's actions? Insulin deficiency suppresses cell-mediated immunity. Hyperglycemia suppresses the activity of macrophages. Impaired glucose metabolism increases mast cell degranulation. Vascular changes with diabetes increase postoperative bleeding.

Consequences of hyperglycemia also include suppression of macrophages and increased risk for wound infection. Changes in glucose metabolism do not increase mast cell degranulation. Insulin deficiency does not suppress cell-mediated immunity. Diabetes mellitus is associated with impaired circulation that contributes to tissue ischemia, not bleeding.

A nurse is explaining how a leukocyte moves through inter-endothelial junctions to the site of tissue injury. Which term should the nurse use to describe this process? Fusion Diapedesis Margination Phagocytosis

Diapedesis is the process in which a leukocyte moves between endothelial cells to enter the tissues. Fusion of a lysosome with a phagosome occurs during phagocytosis after the phagocyte has entered the tissue. Both leukocytes and endothelial cells begin expressing molecules (selectins and integrins) that increase adhesion, or stickiness, causing the leukocytes to adhere more avidly to the endothelial cells in the walls of the capillaries and venules in a process called margination. Phagocytosis is the process by which a phagocyte engulfs a microorganism or other substance.

An older adult client who had an accidental fall is admitted to the hospital. After reviewing the client's laboratory reports, the nurse believes the client is at risk for impaired wound healing. Which finding supports the nurse's conclusion? High zinc levels Increased oxygen diffusion Increased manganese levels High fasting blood glucose levels

Increased blood glucose levels impair epithelialization and impair wound healing. Zinc promotes wound healing, so high zinc levels would not put the client at risk for impaired wound healing. Manganese is required for collagen synthesis; manganese deficiency would impair wound healing. Reduced rather than increased oxygen diffusion impairs wound healing. Reduced oxygen diffusion caused by blood clots and the effects of diabetes lead to impaired wound healing.

Which findings will the nurse observe in a client with local inflammation of the eye? Select all that apply. Pallor Edema Bruising Redness Gangrene

Increased vascular permeability with exudation of plasma into the tissue during inflammation causes edema. Redness (erythema) is caused by increased concentration and slowed movement of red blood cells. Pallor occurs with diminished blood flow to tissues, not with inflammation. Although bruising can occur with trauma, it is not a general manifestation of inflammation. Gangrene is not a manifestation of inflammation but of severe infection.

A client with an upper respiratory tract infection has nasal congestion. During the assessment, the nurse finds that the client's blood pressure is 120/80 mm Hg and rate of respiration is 15 breaths/minute. The nurse should check the client's prescription for which category of medication to help with the congestion? Diuretics Antihistamines Vitamin K supplements Nonsteroidal antiinflammatory drugs

Infection and inflammation increase histamine levels and cause increased vessel permeability and swelling, causing nasal congestion in the client. Antihistamines block the binding of histamine to its receptors, which decreases inflammation and nasal congestion caused by infection. Therefore, the nurse would expect to find antihistamine medications in the client's prescription. Diuretics increase urine output and are used for fluid overload, not Infection. Vitamin K supplements help to treat clotting disorders, but not respiratory infection. Nonsteroidal antiinflammatory drugs help to alleviate pain, but do not reduce nasal congestion.

Which information from the staff indicates effective teaching by the nurse for the first line of defenses against disease? Select all that apply. Intact skin Phagocytes T lymphocytes B lymphocytes Mucous membranes Low skin temperature

Intact skin and mucous membranes provide mechanical and physical barriers that prevent microorganisms from gaining access to the body's tissues. Low temperature and low pH of the skin also inhibit microorganisms. Phagocytes are part of the second line of defense; they fight pathogens once they enter the body. T lymphocytes and B lymphocytes are parts of the third line of defense; they fight pathogens once they enter the body.

Which cytokine deficiency does the nurse suspect is causing delayed wound healing in a client? Interleukin 6 Interleukin 10 Interferon alpha Interferon gamma

Interleukin 6 is a cytokine produced by macrophages, lymphocytes, and fibroblasts. It stimulates the growth of fibroblasts, which are required for wound healing. Interleukin 10 suppresses the growth of lymphocytes as a part of the down-regulation of the immune and inflammatory response. Interferon alpha induces antiviral proteins and limits the spread of viruses by protecting neighboring healthy cells. Interferon gamma activate macrophages to kills viruses and bacteria, thereby enhancing acquired immunity.

Which information from the staff indicates successful teaching by the nurse for cytokines? They include mast cells and basophils. They include interleukins and interferons. They are destructive enzymes contained in lysosomes. They are regulatory chemicals secreted by endocrine glands.

Interleukins and interferons are classified as cytokines. Cytokines constitute a large family of small-molecular-weight soluble intercellular-signaling molecules that are secreted, bind to specific cell membrane receptors, and regulate innate or adaptive immunity. Mast cells are filled with granules and are located in the loose connective tissues close to blood vessels near the body's outer surfaces (i.e., in the skin and lining the gastrointestinal and respiratory tracts) and are involved in inflammation. Basophils are found in the blood and probably function in the same way as tissue mast cells. Cytokines are released by immune cells, not endocrine glands. Cytokines are not destructive enzymes contained in lysosomes; rather, they are mediators of the inflammatory and immune responses.

A client is in the later stages of inflammation. The client's mast cells release leukotrienes that perform which function? Opsonize bacteria Increase vascular permeability Activate the complement cascade Attract neutrophils and eosinophils

Leukotrienes have histamine-like effects in the later stages of inflammation and stimulate increased vascular permeability and smooth muscle contraction. Opsonization is produced by antibodies and specific complement proteins to enhance phagocytosis. The complement cascade is activated by antigen-antibody reactions (classic pathway) or by bacterial polysaccharides (lectin, the alternative pathways, or both). Prostaglandins, not leukotrienes, cause neutrophil chemotaxis. Mast cells contain chemotactic factors for eosinophils.

A client has an infection. Which cells provide long-term phagocytosis against infectious agents? Mast cells Neutrophils Macrophages Natural killer cells

Macrophages are better suited than neutrophils to long-term defense against infectious agents. Macrophages are involved in activation of the adaptive immune system and they have a longer life span since they can divide in the acidic inflammatory site, whereas neutrophils cannot. Mast cells are filled with granules and are involved in inflammation. Neutrophils are the first phagocytic cells at the site of infection; they have short-lived activity because they cannot divide and do not survive in an acidic environment. Natural killer cells do not have the capacity for phagocytosis but kill through other mechanisms.

A nurse is teaching about the functions of macrophages. Besides phagocytosis, which information should the nurse include in the teaching session? Select all that apply. Activation of fibroblasts Release of growth factors Promotion of collagen formation Stimulation of new blood vessel growth Production of neutrophil-chemotactic factor

Macrophages orchestrate the wound healing process by cleaning up the site of injury by phagocytosis, promoting angiogenesis (new blood vessel growth), releasing cytokines and growth factors that promote epithelial cell division, activating fibroblasts, and promoting the synthesis of extracellular matrix and collagen formation. Neutrophils must release macrophage-chemotactic factors to attract macrophages to the area.

When a client's mast cells degranulate, which substance is released? Antibodies Basophils Histamine Complement

Mast cells release inflammatory mediators such as histamine when they degranulate. Antibodies are produced by the acquired immune system. Complement is a set of proteins that circulate in the blood to help fight pathogens. Basophils are found in the blood and probably function in the same way as tissue mast cells.

After interacting with a client, the nurse believes the client has a risk of delayed wound healing due to impaired collagen synthesis and fibroblast proliferation. Which statement made by the client supports the nurse's conclusion? "I hate shellfish so I never eat it." "I drink cranberry juice all the time." "I drink carrot juice with breakfast every morning." "I'm a vegetarian, but I rarely eat beans or legumes."

Meat, nuts, legumes, and beans are rich sources of protein. A client who does not eat meat, beans, nuts, or legumes may have hypoproteinemia, which impairs collagen synthesis and fibroblast proliferation, resulting in delayed wound healing. Shellfish is rich source of iodine, but this does not play a role in wound healing. Orange juice is rich in vitamin C, which helps in collagen synthesis and enhances wound healing. Cranberry juice reduces risk of urinary tract Infection, but does not impair wound healing.

Which information indicates the nurse has a good understanding of pathogen-associated molecular patterns (PAMPs)? PAMPs are an example of a major class of immunity cells that remove cellular debris. PAMPs are an example of a major class of cell-surface pattern recognition receptors. PAMPs are molecules that are expressed by infectious agents through products of cellular damage. PAMPs are molecules that are expressed by infectious agents, either found on their surface or released as soluble molecules.

Molecules that are expressed by infectious agents, either found on their surface or released as soluble molecules, are called pathogen-associated molecular patterns, or PAMPs. Molecules that are expressed by infectious agents through products of cellular damage are called damage-associated molecular patterns, or DAMPs. Toll-like receptors (TLRs) primarily recognize a large variety of PAMPs located on the microorganism's cell wall or surface. Most of the inflammatory cells and protein systems, along with the substances they produce, remove the cellular debris in preparation for healing.

A nurse is asked what the difference is between monocytes and macrophages. How should the nurse respond? Monocytes are phagocytic, macrophages release antibodies. Monocytes release antibodies, macrophages are phagocytic. Monocytes are found in tissues, macrophages circulate in the blood. Monocytes circulate in the blood, macrophages are found in tissues.

Monocytes circulate in the blood, but macrophages are found in tissues. Macrophages and monocytes are phagocytic. Monocytes and macrophages do not release antibodies.

A client injures the left leg. When will the nurse expect substantial numbers of neutrophils to arrive at the site of injury? Within 30 minutes Within 1 to 2 hours Within 6 to 12 hours Within 24 to 48 hours

Neutrophils are the predominant phagocytes in the early inflammatory site, arriving within 6 to 12 hours after the initial injury. Macrophages enter the site after 24 hours or later, but usually arrive 3 to 7 days later.

A client has an injury to the left leg. Which phagocytes will help the client in the early stage of inflammation? Platelets Eosinophils Neutrophils Macrophages

Neutrophils are the predominant phagocytes in the early inflammatory stages. Platelets are not phagocytes but are used to help clotting. Eosinophils are the body's primary defense against parasites and help regulate vascular effects of inflammation. Macrophages enter the site after the neutrophils; neutrophils arrive within 6 to 12 hours, whereas macrophages enter after 24 hours.

A nurse is caring for a newborn. Which age-related factor will the nurse consider that affect innate immunity? Complement levels are elevated. Chemotaxis of monocytes is normal. Gut microbiome is facilitated by intake of formula. The inflammatory responses is transiently depressed.

Newborns have transiently depressed inflammatory responses. The establishment of the gut microbiome is facilitated by breast milk. Monocyte/macrophage numbers are normal but chemotaxis of monocytes is delayed. Complement levels are diminished, especially components of the alternative pathways (e.g., factor B), particularly in premature newborns.

Which process should the nurse include when teaching about how antibodies promote phagocytosis? Diapedesis Chemotaxis Margination Opsonization

Opsonization is the process of increasing the adherence between the phagocyte and the target cell. Both leukocytes and endothelial cells begin expressing molecules that increase adhesion, or stickiness, causing the leukocytes to adhere more avidly to the endothelial cells in the walls of the capillaries and venules, in a process called margination, or pavementing. Leukocyte-endothelial interactions lead to diapedesis, or emigration of the cells through the inter-endothelial junctions that have loosened in response to inflammatory mediators. Once inside the tissue, leukocytes undergo a process of directed migration, called chemotaxis, in which they are attracted to the inflammatory site by chemotactic factors.

While assessing a client, the nurse observes a raised scar at the site of injury. What does the nurse suspect to be the cause of this scarring pattern? Increase in T lymphocytes Increase in collagen levels Increase in white blood cells Increase in tumor necrosis factor

Presence of a raised scar at the site of injury indicates the formation of a keloid. Excessive formation of collagen increases the formation of a keloid. T lymphocytes increase to provide acquired immunity. White blood cells increase if the client has an infection. An increase in tumor necrosis factor causes muscle wasting syndrome, not keloid formation.

Which clients will most likely have wound healing through secondary intention? Select all that apply. A. client who has a cut to the hand from chopping vegetables. B. Client who has a surgical incision. C. Client who has a stage IV pressure ulcer D. Client who has wounds due to an accidental fall E. Clients with second-degrees burns on the arm from hot oil

Stage IV pressure ulcers require large amounts of tissue replacement, which prolong epithelialization and lead to shrinkage of the wound. Therefore, Client C would have wound healing through secondary intention. Extensively damaged tissue that cannot be sutured or otherwise closed, such as burned skin, is also allowed to heal by secondary intention. Presence of a cut to the hand indicates that the client has a minor wound and minimal tissue loss, so Client A will have wound healing through primary intention. Surgical incisions and wounds due to accidental falls are minor wounds. Therefore, the wounds in Clients B and D would heal through primary intention.

The nurse is caring for a client with arthritis who is scheduled for knee replacement surgery. After reviewing the client's medical history, the nurse finds that the client is at risk for delayed wound healing. Which medication did the nurse find in the client's medical history? Steroid Antihistamine Vitamin C supplement Potassium-sparing diuretic

Steroids inhibit migration of macrophages to the site of injury, and delay epithelialization and wound healing. Antihistamine medications do not impair platelet aggregation and do not impair wound healing. Vitamin C supplements enhance collagen formation and improve wound healing. Potassium-sparing diuretics will not impair epithelialization and do not impair wound healing.

After reviewing the history of a client with recurrent infection, the nurse finds that the client has impaired adaptive immunity. Which finding supports the nurse's conclusion? The client has a T cell deficiency. The client has a low platelet count. The client has a low neutrophil count. The client has an erythrocyte deficiency.

T lymphocytes form the third line of defense and play a major role in adaptive or acquired immunity. Therefore, deficiency of T cells impairs adaptive immunity. Platelets play a role in blood clotting. A decrease in the platelet count increases the risk of bleeding, but does not impair acquired immunity. Neutrophils form the second line of defense and a decrease in neutrophils impairs innate immunity. A decrease in erythrocyte levels increases the risk of anemia.

Which body fluids and secretions contain lysozymes that protect the client from invasion of gram-positive bacteria? Select all that apply. Tears Saliva Mucus Perspiration Sebaceous glands

Tears, saliva, and perspiration contain a lysozyme that attacks the cell walls of gram-positive bacteria. Mucus traps foreign particles and bacteria to limit their potential to cause harm. Sebaceous glands secrete fatty acids and lactic acid that kill bacteria and fungi.

Which assessment findings are classic for a client with inflammation of the knee? Select all that apply. Painful knee Pallor of the knee Warmth of the knee Swelling of the knee Loss of knee movement

The classic or cardinal signs of acute inflammation include redness (rubor, erythema), heat (calor), swelling (tumor), pain (dolor), and loss of function (functio laesa). Pallor is not a classic sign of inflammation; redness is.

A client had surgery two days ago. As part of the postoperative discharge education, the nurse teaches the client about prescribed activity limitations for the next few weeks. The client lets the nurse know that going back to work quickly is essential. Which principle should underlie the nurse's response? Inflammation is the necessary first stage of tissue healing. When epithelialization has occurred, tissue healing is nearly complete. Primary intention heals open wounds; rest and good nutrition will help it heal faster. Proliferation and remodeling stages are necessary for a healing wound to be strong.

The client needs to know that tissue healing has several stages and that the incision is not yet healed and strong. Early return to work and increased stress on the healing wound may impair effective healing. Although inflammation is the necessary first stage in healing, this does not address the issue that it will take time to complete healing of the surgical incision. Epithelialization occurs during phase II of tissue healing, well before the healing is complete. Secondary, not primary, intention heals open wounds.

During tissue injury and inflammation, the client's clotting system is activated. While planning care, the nurse chooses interventions based on which functions of the clotting system? Select all that apply. Stops bleeding Initiates cell lysis Inhibits mast cells degranulation Prevents the spread of infection Releases prostaglandins from platelets Provides a framework for future healing

The clotting cascade helps stop any bleeding, prevents the spread of infection, and provides a framework for future healing. Clotting does not involve cell lysis. The clotting system does not inhibit mast cell degranulation. Prostaglandins are synthesized by mast cells.

A client asks what it means when the primary healthcare provider refers to the complement system in regard to infection. What is the nurse's best response? The complement system is a sequence of chemical messengers secreted by immune cells to help fight an infection. The complement system is a set of proteins in the blood that help activate the body's inflammatory and immune response to infection. The complement system is a kind of antibody that normally circulates in bodily fluids. When such an antibody encounters bacteria, it helps to fight infection. The complement system is a type of immune cell that circulates in the blood. When these cells become activated, they help to protect us by producing antibodies.

The complement system is a set of proteins in the blood that help activate the body's inflammatory and immune response to infection, especially bacterial. The complement system is not a sequence of chemical messengers secreted by immune cells, a type of immune cell, or an antibody.

The nurse is caring for a client after an accident. Which interventions should be included in the client's care plan to prevent contracture of tissue at the site of injury? Select all that apply. Providing adequate amount of fluids Placing the client in a proper position Performing range-of-motion exercises Encouraging the client to do guided imagery Administering nonsteroidal antiinflammatory drugs

The nurse should perform range-of-motion exercises and place the client in a proper position to prevent muscle damage and contracture of tissues. Providing adequate fluids helps to prevent dehydration. Encouraging the client to do guided imagery provides relaxation and reduces stress. Antiinflammatory medications provide pain relief, but do not prevent contracture of tissue at the site of injury.

A nurse is asked about the primary function of plasmin in the body. What is the nurse's best response? It degrades histamine. It degrades bradykinin. It degrades blood clots. It degrades dead antibodies.

The primary activity of plasmin is to degrade fibrin polymers in clots; plasmin is a component of the fibrinolytic system. Plasmin does not remove dead antibodies. Kininases help degrade kinins, not plasmin. Histaminase degrades histamine, not plasmin.

A nurse is providing wound care and observes that the client is healing normally and is in the proliferative phase of wound healing. What will the nurse observe? Dehiscence Epithelialization Scar tissue remodeling Mast cell degranulation

The proliferative phase is characterized by macrophage recruitment of fibroblasts (connective tissue cells) and fibroblast proliferation, followed by fibroblast collagen synthesis, epithelialization, contraction of the wound, and cellular differentiation. Dehiscence is a complication that occurs when sutured wound edges pull apart. Scar tissue remodeling occurs during phase III of tissue healing (remodeling and maturation). Mast cell degranulation is the first response to cell injury, leading to inflammation from release of histamine.

How should a nurse support a hospitalized client's first line of defense against microorganisms? Turn frequently Administer antibiotics Monitor body temperature Educate about immunizations

The skin and mucous membranes are the first barriers (the first line of defense) that microorganisms encounter when attempting to enter the body. Nursing actions that promote skin integrity, such as turning to relieve pressure, keep the skin intact. Antibiotics treat infection but do not support the first line of defense against infection. Immunizations play a role in supporting adaptive immunity as a third line of defense. Although monitoring body temperature is part of a nursing assessment for infection, it does not support the first line of defense.

A client has activated the complement system during an inflammatory response to an injury. When planning care, which information should the nurse remember about which substance activates complement? Histamine Antibodies Leukotrienes Prostaglandins

Three major pathways control the activation of complement. The classical pathway is primarily activated by antibodies. The alternative pathway is activated by several substances on the infectious organisms (endotoxins and zymosan). The lectin pathway is activated by mannose-binding lectin, a plasma protein. Histamine is an early mediator of this inflammatory response. It is a potent vasodilator. Leukotrienes are inflammatory chemicals that produce histamine-like effects. Prostaglandins are inflammatory chemicals that contribute to vasodilation, pain, and increased capillary permeability.

While planning care for a client with inflammation, the nurse recalls that vasodilation and increased vascular permeability include which benefits? Select all that apply. They dilute bacterial toxins. They stimulate differentiation of antibodies. They transport neutrophils to the area of injury. They bring macrophage cells to the area of injury. They reduce heat produced by chemical mediators.

Vasodilation and increased vascular permeability dilute toxins through an influx of plasma. They also bring leukocytes, including lymphocytes, neutrophils, and macrophage cells, to the area of injury. Increased blood flow produces heat in the area of injury. The vascular changes of inflammation do not have a direct effect on production of antibodies.

A client states, "I have a sore throat, and it's red." When the client asks why it is red, how should the nurse respond? More platelets are moving from your blood vessels into the lining of your throat. The cells that line your throat are doing a healing process called regeneration. Your blood vessels in the area have relaxed to allow more blood into the area to promote healing. Chemical messengers from your inflamed throat put out a distress signal that brings more white blood cells to the area.

Vasodilation that allows increased but slowed blood flow causes the redness of inflammation. The condition is inflammation rather than regeneration. Secretion of cytokines (chemical messengers) is not the direct cause of the redness of inflammation. Phagocytes (white blood cells) enter the area but do not cause the redness of inflammation. Platelets are involved in clotting.

While interacting with a client who was in a motor vehicle accident, the nurse suspects that the client is at risk for impaired wound healing. Which statement made by the client supports the nurse's suspicion? "I don't drink coffee." "I eat a lot of bananas." "I take Tylenol every day." "I hate fruit, especially citrus."

Vitamin C increases collagen synthesis and enhances tissue healing. If the client does not like fruit, especially citrus, he or she may be less likely to get enough vitamin C and that can impair wound healing. Coffee contains caffeine and does not play a role in wound healing. Tylenol is an analgesic that helps to relieve pain and has no impact on wound healing. Bananas are a good source of potassium, but do not necessarily enhance wound healing.