Course Point Unit 3

Select the statement that best describes the formation of a keloid.

"Benign, tumor-like mass"

The parents of a child diagnosed with rheumatic disease are shocked by the diagnosis and tell the nurse that they did not think children could acquire the disease. The best response would be:

"Children can be affected with almost all of the rheumatic diseases that occur in adults."

Which statement will the nurse include when teaching a client with Crohn disease about dietary restrictions during an exacerbation?

"Eat foods low in fat and fiber."

A client has been diagnosed with rheumatoid arthritis (RA). What will the nurse tell the client about this disorder's etiology?

"Genetic predisposition is very likely."

The nurse is caring for a client who reports chronic joint pain. Which statement(s) by the client indicates that the client most likely has rheumatoid arthritis? (Select all that apply.)

"I have been so tired lately." "I have a low-grade fever on and off." "My joints feel warm to the touch." "I don't have much of an appetite."

The nurse is providing discharge instructions for a postoperative client. The nurse determines the teaching is effective when the client verbalizes which statement about wound healing?

"I will regain almost full-tensile strength of an unwounded skin at the end of 3 months."

The nurse has just finished teaching a client newly diagnosed with rheumatoid arthritis about the disease. The nurse determines that teaching is effective when the client makes which statement?

"Rheumatoid arthritis includes joint involvement that is usually symmetric and polyarticular."

A nurse is caring for a client who has a laceration on the forearm. The client reports swelling and pain. Which statement is used in teaching about the condition?

"There is a release of histamine, leukotrienes, and prostaglandins."

The nurse is teaching the client with rheumatoid arthritis (RA) about the role of corticosteroid therapy in disease management. What information does the nurse include about the use of corticosteroids in RA? Select all that apply.

-Are reserved for poorly controlled, systemic symptoms -Can increase the risk for opportunistic infections -Do not affect disease process or prevent joint damage

A client is suspected to have developed chronic inflammation. Select the potential causes of the chronic condition. Select all that apply:

-Asbestos -Silica -Suture -Talc -Tubercle bacillus

The nurse is caring for a client with psoriasis. What information about psoriatic arthritis does the nurse provide to the client? Select all that apply.

-It is a relatively rare complication, affecting less than 10% of people with psoriasis. -Using disease-modifying drugs for the psoriasis can help control arthritis symptoms. -The presentation can vary widely in affected joints and associated symptoms.

A client is being seen in the dermatology clinic for a follow-up appointment for a second-degree full-thickness burn. What are characteristics of second-degree burns? Select all that apply.

-Painful -Blistered -Mottled, pink red

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.

-The client's ankle is visibly red -The ankle appears to be swollen -The ankle is warmer than the unaffected ankle -The client is experiencing pain

The nurse is assessing a client with reports of knee joint pain. Which findings does the nurse document as supporting osteoarthritis? Select all that apply.

-The joint is firm upon palpation -Crepitus is felt with joint movement -The client's body mass index is 35

The nurse works in an outpatient wound center. Which client presentation will result in documentation pertaining to wound healing by secondary intention? Select all that apply.

-client with wound on the lower calf resulting from the leg touching a motorcycle muffler -client with stage 3 decubitus pressure injury that extends into the tissue beneath the skin, forming a small crater with fat showing in the sore -client with a large abscess on the roof of the mouth following a root canal that is not healing with brushing of the teeth or gargling with mouthwash

A client is admitted to the hospital with superficial (first-degree) and partial-thickness (second-degree) burns. Which assessment finding(s) is associated with superficial (first-degree) burns? Select all that apply.

-red or pink -painful

The nurse is caring for a client who has suffered a burn injury to the anterior and posterior of the right arm, groin, and anterior right lower leg. According to the rule of nines, what is the estimated extend of the client's burn injury?

19%

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

Which client likely faces the greatest risk of a gastrointestinal bleed?

A client who takes aspirin with each meal to control symptoms of osteoarthritis

A 79-year-old woman reports a recent onset of "nearly constant heartburn." During the assessment interview, she states that she has "lots of aches and pains." She states that she is not on any prescription medications but often takes aspirin for pain. The nurse should suspect what diagnosis?

Acute gastritis

A client who is morbidly obese has developed extensive skin breakdown from the excess skin overlapping in the lower abdomen (known as a pannus). The client states not being concerned about the wound because there is very little bleeding. Which statement best describes why this wound may not be properly healing?

Adipose tissue has fewer blood capillaries; therefore, the body needs to generate new blood vessels for more oxygen exchange and bring nutrients to the wound area.

A client with a severe burn injury is treated at a burn center. After the client's airway, breathing, and circulation are stabilized, what is the nurse's priority of care?

Administering intravenous fluids to replace lost water and sodium

A nurse is researching the prevalence and risk factors of inflammatory bowel disease (IBD). Which ethnicity does the nurse discover has four to five times greater prevalence than other groups?

American Jewish

When assessing the client with acute pancreatitis, which of these diagnostic tests—consistent with the disease— does the nurse anticipate will be altered?

Amylase and lipase

Which condition is an example of wound healing by secondary intention?

An infected burn of the arm

A client is suspected to have autoimmune gastritis. Which finding on the pathology report would be a positive diagnosis of this condition?

Anti-IF antibodies

The nurse is caring for a client with chronic pancreatitis who reports abdominal pain. Which location will the client's pain radiate?

Back

A nurse is caring for a client admitted for a systemic infection. The client has leukocytosis. What other laboratory value does the nurse anticipate the health care provider to order?

C-reactive protein (CRP)

A client underwent an open cholecystectomy 2 days ago, and the incision is now in the proliferative phase of healing. What is the dominant cellular process that characterizes this phase of the client's healing?

Collagen secretion by fibroblasts

A young client presents reporting diarrhea, fecal urgency, and weight loss. The stool is light-colored and malodorous, and it tends to float and be difficult to flush. The client has also noted tender, red bumps on the shins and reports pain and stiffness in the elbows and knees. Sigmoidoscopy reveals discontinuous, granulomatous lesions; no blood is detected in the stool. Which diagnosis would his care team first suspect?

Crohn disease

When assessing a client's incision, the nurse notes that the edges of the once approximated incision has begun to pull apart. The nurse documents that the client's incision has:

Dehisced

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

The nurse is teaching her client with hepatobiliary disease about her diet. She tells her that she may have steatorrhea, which is the malabsorption of which dietary component?

Fat

Which response by the nurse answers a client's question regarding the most common objective sign of systemic inflammation during the acute-phase response?

Fever

When caring for a client during the proliferative phase of wound healing, the nurse teaches the client that which of these processes is taking place?

Fibroblasts secrete collagen for wound healing.

Crohn disease has a distinguishing pattern in the gastrointestinal (GI) tract. The surface has granulomatous lesions surrounded by normal-appearing mucosal tissue. A complication of the pattern includes:

Fistula formation

The nurse is caring for a client who has had a full leg cast for the past 6 months. What teaching should the nurse offer about using the affected leg?

Gradually increase exercise, engaging in activities like swimming or cycling.

A client fell off his motorcycle, receiving several large abrasion-related surface wounds. What physiologic phenomenon will the client first experience?

Healing by secondary intention

An older adult client has had mobility and independence significantly impaired by the progression of rheumatoid arthritis (RA). What is the primary pathophysiologic process that has contributed to this client's decline in health?

Immunologically mediated joint inflammation

A client is newly diagnosed with irritable bowel syndrome (IBS). The nurse explains how the nervous system affects gastrointestinal (GI) disorders. The nurse mentions which statement in regard to IBS?

Increase in parasympathetic nervous system activity

Crohn disease is treated by several measures. Treatment with sulfasalazine will focus on which aspect of this disease?

Inflammatory suppression

When caring for a client with a pressure injury, the nurse collaborates with the provider to obtain a prescription for which of these interventions to promote wound healing?

Keep dressing of the wound bed moist.

What laboratory markers are most commonly used to diagnose acute pancreatitis?

Lipase and amylase

What function does hyaluronic acid (a component of the extracellular matrix) perform in the body?

Lubricates joints and serves as a supportive structure in the extracellular space throughout the body.

The relative of a client with osteoarthritis asks how to avoid developing the condition. Which response by the nurse is most accurate?

Maintain your weight near ideal.

The nurse is caring for a client with chronic gastritis. The client is about to have a breath test to diagnose H. pylori infection. How does this test work?

Measures the presence of an enzyme given off when the bacterium converts urea to carbon dioxide in the lungs.

The nurse reviews the endoscopy report for a client diagnosed with ulcerative colitis. Which finding is in the report?

Mucosal erythema

Which represents the definitive test for rheumatoid arthritis (RA)?

No definitive test exists

The nurse caring for a postoperative client documents that the surgical incision is healing by:

Primary intention

The nurse is assessing the wound of a postoperative client. The client has a 6-inch abdominal wound that is well approximated and closed with surgical suture. The wound does not display any redness or drainage. The nurse would document the healing process as:

Primary intention

A client sustained an injury 3 days ago. The nurse is assessing the status of the wound and anticipates the wound to be in which phase of healing?

Proliferative

A client was diagnosed with Salmonella 1 week ago and is now experiencing joints that are warm, swollen, and tender; fever; and weight loss. What is the most likely interpretation of these manifestations?

Reactive arthritis

The nurse would identify the presence of granulation tissue at a wound site by which characteristic?

Red, moist tissue

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

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

Rubor, swelling, and pain

A client has a burn that involves the entire epidermis and various degrees of the dermis. It is painful, moist, and blistered. The nurse recognizes the burn as:

Second-degree partial thickness

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

Serous

Inflammatory bowel disease (IBD) is used to designate two related inflammatory intestinal disorders: Crohn disease and ulcerative colitis. The nurse recognizes the difference between the distribution pattern between Crohn disease and ulcerative colitis. Which pattern describes Crohn's disease?

Skip lesions

When caring for a client with a wound that is healing by primary intention, the nurse recognizes which characterization best describes this type of wound?

Surgical incision

Why is H. pylori infection so difficult to treat?

The infection is deep in the stomach mucosa.

A nurse is caring for a client with a fever. The client is requesting more blankets and to increase the room temperature. Which biological action occurs as a result of the pyrexia in a client?

The temperature stimulates the phagocytosis of microorganisms.

A client is admitted to the hospital with partial-thickness (second-degree) burns over 30% of the body. What is a characteristic of partial-thickness (second-degree) burns?

They involve the dermis and the epidermis.

The nurse is caring for a client who has experienced hypovolemic shock secondary to penetrating multiple trauma. When caring for the client postoperatively, which of these factors does the nurse recognize places the client at risk for poor wound healing?

Tissue hypoxia

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):

Ulceration

The nurse is caring for an obese client who has had abdominal surgery. The medical record states the wound has developed a dehiscence. Which finding does the nurse anticipate observing when changing the dressing?

Wound edges are 1.5 inches apart.

The nurse is assessing a client for acute inflammation of a wound. Which symptom does the nurse attribute to the acute inflammatory response?

edema

After many years of cigarette smoking, a client is admitted to have a "mass" removed from the lung. When explaining the surgery and recovery, the physician notes that the client is likely to have a good amount of fibrosis develop at the surgical area. After the physician leaves the room, the client asks the nurse what was meant by "fibrosis" in the lung. The nurse bases the response on the fact that tissue repair can:

esult in replacement tissue in the form of connective (fibrous) tissue, which leads to scar formation or fibrosis of the lung.

The surgeon has documented that a client is developing "proud flesh" at the postoperative wound site. The nurse recognizes this as:

excessive granulation tissue.

Inflammation can be either local or systemic. What are the most prominent systemic manifestations of inflammation?

fever, leukocytosis or leukopenia, and the acute phase response

A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as a/an:

increase in circulating neutrophils.

While the nurse is performing a skin assessment on a dark-skinned client, the nurse notes that the client has a healed wound on the leg but that the wound has an excess of scar tissue. The nurse documents this as:

keloid.

While reviewing the phases of wound healing, the students note that the first cells to arrive after the injury are the:

neutrophils.

A client comes in with a mild sunburn. Which term best describes the sunburn?

superficial (first-degree) burn

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 and resulting in the red color and warmth.

The nurse is assessing a client with acute sinusitis. What is the primary cause of this condition?

viral infection transmitted via respiratory droplets