MEDSURG EAQ's CH16 Inflammation

After providing teaching about inflammation for a pt with a sprained ankle, which statement made by the pt indicated the need for further education?

"inflammation means that an infection is present" RATIONALE inflammation can occur without infection swelling and redness around the injured ankle is an inflammatory response

How does the nurse respond when a patient voices concerns about infection after noticing a small area of redness around an IV insertion site?

"redness is a Hallmark of inflammation, and inflammation is not always accompanied by infection" RATIONALE Redness is a classical sign of inflammation. Although inflammation may be accompanied by an infection, an infection is not always present when information is present. The redness could have several causes, including irritation of the skin by the cannula, a reaction to the infused medication, or a mild infection. The redness is not unexpected side effect. It is inappropriate for the nurse to tell the patient to not worry. Redness without other clinical manifestations does not indicate a blood infection. Redness is sometimes associated withininfections it is inaccurate to tell the patient otherwise

the nurse includes which education related to inflammation when providing discharge teaching for a pt after a modified radical mastectomy?

"report any increased redness, swelling, warmth, or pain to your health care provider" RATIONALE instruction on increased signs and symptoms of inflammation could reveal signs of potential infection and is most important

Assessment findings of a pt in an ED include partial-thickness second degree burns caused by sun overexposure, intact blisters over the most severely burned areas,and moderate pain. Which statement does the nurse include in the pt's discharge information?

"you may exude pus from the most severely burned areas as the inflammatory process proceeds; this should not be mistaken as a sign of infection" RATIONALE the normal progression of inflammatory response includes formation of pus but does not indicate the presence of infection, though it can be associated w/ infection

What is a function of leukocytes? select all that apply

-destroy foreign invaders -help with complement activation -produce antibodies against invaders -help in recognizing self versus non-self RATIONALE leukocytes destroy foreign invaders, cell debris, and abnormal self cells. They produce antibodies against foreign invaders and help in complement activation. They are additionally responsible for recognizing self versus non-self cells and produce cytokines to INCREASE specific leukocyte activity pg307

which cell is involved in the general inflammation process? select all that apply

-eosinophils -neutrophils -basophils -macrophages RATIONALE neutrophils and macrophages use phagocytosis to destroy and eliminate foreign invaders basophils and eosinophils release chemicals that act on blood vessels to cause tissue-level responses that help neutrophil and macrophage actions

when studying pictures taken from a pt's blood smear, the nurse expects which cell to appear as an immature cell rather than a mature cell? select all that apply

-monocytes -band neutrophils RATIONALE immature cells circulating in the blood include monocytes, tissue mast cells and band neutrophils. mature, active cells include basophils, eosinophils, and segmented neutrophils

Which statement about stage II of the inflammatory response is correct? select all that apply

-neutrophils attack and destroy organisms -there is an increased number of circulatory neutrophils -pus contains dead wbc's, necrotic tissue, and fluids

Which of the following information should be included when providing an education about the healing process involved with myocardial infarctions? Select all that apply

-the heart muscle is a nondividing tissue -WBC's trigger new blood vessel growth - scar tissue prevents the formation of a hole in the muscle wall as ischemic cells die RATIONALE when MI occurs, WBC's trigger new blood vessel growth and scar tissue formation. Scar tissue prevents the formation of a hole, it only serves as a patch, and it does not contract or serve as heart muscle so the effectiveness of the left ventricular contraction is reduced pg.313

what is the maturational pathway a stem cell takes when it differentiates and matures into a platelet? place in correct order

1. hematopoietic stem cell 2. multipotent stem cell 3. myeloid progenitor cell 4. megakaryocyte

Which is the name of the process used to make antigens less likely to grow in the body, just making them effective for immunizations?

Attenuation RATIONALE Attenuation is the process of making an antigen less effective so it can be administered for therapeutic purposes

The nurse Recalls that which type of leukocyte releases histamine and heparin and areas of tissue damage?

Basophil RATIONALE Basophils secrete histamine and heparin in areas of tissue damage. Heparin inhibits blood in proteins clotting. Histamine constrict small veins, thereby inhibiting blood flow and decreasing venous return. Eosinophils play an important role during allergic reactions and have a weak phagocytic action. Plasma cells secrete immunoglobulins in response to a specific antigen. The main function of neutrophils is nonspecific ingestion and phagocytosis of micro organisms in foreign proteins.

What type of white blood cell is MOST involved in immunoglobulin E (IgE)?

Basophils RATIONALE basophils and tissue are the primary types of wbc's involved in IgE presentation p.311

The nurse expects which finding in a complete blood count with differential in a patient with chronic sinusitis?

Basophils 4% RATIONALE The normal count for basophils (basos) is 0.5%; an elevated count indicates inflammation which is common with chronic sinusitis. Segmented neutrophils (segs) are mature neutrophils, which, along with macrophages, eliminate invaders (infection) by phagocytosis; 62% is a normal neutrophil count. For lymphocytes (lymphs), 28% is a normal count in the differential. For band neutrophils, 4% is a normal count; bands are elevated only when infection is present, and the bone marrow cannot keep up with mature segmented neutrophils.

The cells involved in inflammation and immune response are produced where in the body?

Bone marrow RATIONALE bone marrow produces immature stem cells that may mature to form RBC's and WBC's pg311

How does an anti-inflammatory drug inhibit inflammation in the human body?

By preventing enzyme cyclooxygenase from converting arachidonic acid into mediators that inhibit inflammatory response RATIONALE Anti-inflammatory drugs act on the Arachidonic acid cascades that promote inflammatory response. They prevent the conversion of arachidonic acid to chemical substances, which are further processed into mediators, by acting on the enzyme cyclooxygenase

Which cell in a human body is a non-self cell? Select all that apply

Cancer cell, infected body cell RATIONALE B lymphocytes and T lymphocytes contribute to the immune system of the body. Natural killer are special cells that help in cell mediated immunity, they are most effective on unhealthy or abnormal self cells

The nurse expect an increased level of which side of keen in a patient experiencing stage I of inflammation?

Colony stimulating factor RATIONALE Colony stimulating factors released during stage one of inflammation to trigger bone marrow to shorten the time needed to produce white blood cells Heparin and serotonin are not cytokines. Interlucan to is a cytokine involved in lympocyte production which is involved in antibody mediated immunity rather than the nonspecific inflammatory process.

The nurse identifies that which aspect of the inflammatory process may be inhibited when a patient who routinely takes antihistamines experiences a fracture?

Constriction of small veins RATIONALE Histamines are released from basil fills in function to constrict small blood vessels, inhibiting blood flow and decreasing venous return. Therefore a patient who is taking antihistamines will have an inhibited construction process.

The nurse administers an anti-inflammatory medication to a patient and recalls the mechanism of action of the drug is inhibition of which enzyme?

Cyclooxygenase (COX) RATIONALE COX helps prevent Arachidonic acid into mediators that promote inflammatory responses and tissues. Therefore, many anti-inflammatory medication, including NSAIDS, function by inhibiting COX activation. Amylase is an enzyme used to break down starch, neuraminiside is used to help release viruses from cells, and glucokinase phosphorylates glucose to glucose-6-phosphate

Which type of blood cells effective during a viral infection?

Cytotoxic T cells RATIONALE Cytotoxic T cells destroy the cells that contain human antigens (HLAs); this is the most effective activity performed against self cells infected by invader such as viruses or Protozoa. Neutrophils are crucial in controlling bacterial infections. Helper T cells recognize self versus non-self cells secrete cytokines to enhance the function of the white blood cells against the non-self cells. Suppressor T sells prevent immune over reactions

The nurse suspects that which laboratory can't will be increased in a patient who is experiencing recurrent episodes of allergic manifestations?

Eosinophil count RATIONALE In an allergic response, there is typically an increase in the number of circulating eosinophils. Basophils caused vascular leak syndrome in response to tissue injury. Platelets play a key role in controlling bleeding. Neutrophils are responsible for tackling infections

Which white blood cell type does the nurse expect to be most active in a patient who presents to the emergency department with roundworm, a parasitic infestation?

Eosinophils RATIONALE eosinophils are very active against parasitic infestations such as roundworm

The nurse is caring for children in the emergency department and concludes that the most widespread inflammatory response will be found in the patient with which injury?

Fractured leg, chest contusion, and a dislocated shoulder from a motor vehicle accident RATIONALE The child in the motor vehicle accident has multiple injuries to multiple parts of the body. This will result in a widespread, potentially whole body inflammatory response

Which is a key function of neutrophils?

Help in nonspecific ingestion and phagocytosis of microorganisms RATIONALE neutrophils help in nonspecific ingestion and phagocytosis of microorganisms and foreign particles pg311

What information needs to be included when comparing inflammatory response with antibody mediated immunity (AMI) and Cell mediated immunity (CMI) responses? Select all that apply

It is an immediate response; AMI and CMI are delayed responses It is a short term response; AMI and CMI are long-term responses RATIONALE Inflammation is an immediate and short term, nonspecific, localized response to invasion with a foreign organism or to injury. Information does not recognize organisms upon repeated exposure. In contrast, AMI and CMI are delayed, long term, specific responses to infection

Which functional age related changes in the older adult occurs during the immune component of inflammation?

Leukocytosis does not occur during an acute infection RATIONALE Luco cytosis does not occur during a cute infection in the older adult in the immune component of information. A decline in natural antibodies and a decreased response to antigens occur during the immune component of antibody mediated immunity. In the older adult, there is a decrease in the numbers of circulating T lymphocytes that occur in the immune component of cell related immunity, not inflammation

The nurse reviews the results of a patient white blood cell differential and is concerned when which leukocyte makes up less than 5% of total WBC count?

Lymphocytes RATIONALE Lymphocytes usually make up about 20% at 40% of the total WBC count. In contrast, basil fills make up .5% to 1% of the total WBC count. Eosinophils make up 1% to 4% of the count. Monocytes make up 2% to 8% of the count.

The nurse notices the ear canal of a pt is red and inflamed. Which cell would be most active in the first stage of inflammation?

Macrophages RATIONALE macrophages are the primary cells that affect the first stage of the inflammatory process. Macrophages secrete cytokines to mature wbc's faster. p.127

Which inflammatory condition is caused by infection? select all that apply

Meningitis Pneumonia

Which of the following statements indicates a need for further learning about the inflammatory response?

Monocytes have the same activity as macrophages they just reside in the blood rather than in the tissues RATIONALE Monocytes primarily reside in the blood in an immature form. This immature form has limited activity. Once they move into tissues, they mature into macrophages. Therefore monocytes and macrophages do not have the same activity. Because macrophages are the mature form of monocyte, they are both derived from the same stem cells, in this case myeloid stem cells. In addition, macrophages can be either fixed with an a tissue, or they can move within and between tissues if needed

which type of white blood cell acts by limiting inflammation and may result in infection if the number of these cells decreases?

Neutrophils RATIONALE it takes 12 to 14 days for stem cell to produce mature neutrophils, if infection persists bone marrow has less time for the maturation of neutrophils

Which inflammatory reaction in the human body is caused by an infection? Select all that apply

Otitis media, appendicitis RATIONALE In the human body, infections may give rise to inflammatory reactions. Otitis media, an infection of the middle ear, and appendicitis, an infection of the appendix, are infections associated with inflammation.

The nurse recalls that which skin abnormality is not associated with an increased risk for infection at the site? Select all that apply

Rash, intact blister RATIONALE A rash is usually the body's response to an allergen rather than an infectious agent. A blister is usually the body's response to a minor burn or a sheering force rather than infectious agent. Because neither of these conditions break the skin barrier they are less likely to develop an infection

When a patient experiences an adverse reaction to a blood transfusion, the nurse recalls that which step in the phagocytosis process is most responsible for initiating this type of response?

Recognition RATIONALE The adverse reaction will not begin until the body recognizes the foreign blood cells as non-self, which occurs in the recognition phase. This triggers the phagocytosis of the foreign blood cells and a widespread inflammatory reaction.

After noting increased Eosinophils in the laboratory results of a patient with an allergic response, the nurse recalls which function of this type of leukocyte?

Release vasoactive amines RATIONALE There is an increase in the number of Eosinophils during an allergic response. Eosinophils granules contain certain enzymes that degrade vasoactive chemicals released by other leukocytes. Basophils release histamine and heparin in areas of tissue damage. Monocytes destroy bacteria and cellular debris. Plasma cells secrete immunoglobulin in response to the presence of a certain antigen

Which condition does the nurse suspect in a patient with a white blood cell differential count that indicates Bandemia?

Sepsis RATIONALE Problems such as sepsis caused the circulating neutrophils to change from being mostly segmented neutrophils to being less mature forms. This situation is a left shift or Bandemia (sometimes called a shift to the left) because the segmented neutrophil (at the far right of the neutrophil pathway) is no longer the most numerous type in circulation. Instead, more of the circulating cells are bands — the less mature cell type found father left on the neutrophil maturational pathway. In auto immune disorders such as lupus, bone marrow disorders, and radiation therapy there would be a decrease in the white blood cell count because of decreased immunity.

Which of the following component of innate immunity needs to be discussed when teaching about immunology? Select all that apply

Skin, natural killer cells RATIONALE Skin forms a barrier to prevent infiltration for an organisms, natural killer cells target foreign cells for destruction. Both of these are part of innate immunity. Lymphocytes, antibodies, and memory cells are all part of antibody mediated immunity rather than mediated immunity

The nurse observes a reddened area on the hip of a patient who is on bed rest and identifies which stage of inflammation when the patient denies pain at the site?

Stage I RATIONALE Redness and warmth occur as a part of stage one of the inflammatory process. If the patient is not experiencing pain, the inflammation is likely very mild. The formation of pus exudate occurs during stage II and is often accompanied by pain, in this stage the arachidonic acid cascade starts to increase inflammation. Stage three features tissue repair and replacement.

The nurse recalls which information about neutrophils in an older adult who is experiencing inflammation?

The activity of neutrophils is reduced RATIONALE The nurse is aware that the activity of the neutrophils in an older adult is reduced in the presence of inflammation. It does not mean the neutrophils eradicated the microbe. Although older adults may have an infection and not show expected changes in white blood cell count, a normal neutrophil count is not indicative of a minor infection. The neutrophil count does not remain fixed in the presence of inflammation

Which of the following statements is a good description of Otitis Media?

The inflammatory response is triggered by the invasion of foreign organisms RATIONALE Inflammation is the process that occurs in response to invasion by organisms. In Otiitis media, it is bacteria. Macrophages and neutrophils are involved in inflammation; otitis media is an inflammation caused by infection Immature neutrophil forms should not be in the blood; the change in form is caused by infection, such as sepsis. Immune system cells take action when encountering a non-self or foreign proteins to neutralize, destroy, or eliminate a foreign invader, but this does not cause inflammation

Which explanation does the nurse offer when a patient with joint inflammation asks about the cause of the symptoms? Select all that apply

Warmth caused by increased vascularity in the tissues. Redness is caused by increased vascularity in the tissues. Edema is caused by the leakage of plasma into the tissues. RATIONALE Redness and warmth at the inflammatory site is due to increased vascularity in the area. Adema is due to the leakage of plasma at the inflammatory site. Pain is felt because of inflammatory mediators and Edema, not because of lysosomal enzymes. Reduce function of the joint is not a result of weakness, but of pain and Edema

which change does the nurse expect to see in the WBC differential of a pt with a 5 day history of a sinus infection and large amounts of nasal exudate?

an increase in band neutrophils RATIONALE if infection lasts longer than a few days, then bone marrow cannot keep up with the production of mature segmented neutrophils, so it begins to release band neutrophils. Basophils and lymphocytes will be increased and neutrophils will be decreased

which step of phagocytosis includes bringing the WBC into direct contact with the target?

attraction RATIONALE attraction is the 2nd step of phagocytosis exposure and invasion occur as the first step in response to injury or invasion adherence is the third step, binds the phagocytic cell to the surface of the target recognition, the fourth step occurs when phagocytic cell sticks to the target cell and recognizes it as non self

the nurse identifies that which immune cell is highly active during a patient's type I hypersensitivity reaction?

basophils RATIONALE highly reactive during allergic and hypersensitivity reactions bc of the presence of immunoglobulin E (IgE) on their surfaces

the nurse is caring for children in the ED and concludes that the most widespread inflammatory response will be found in the pt with which injury?

fractured leg, chest contusions, and dislocated shoulder form a MVA RATIONALE the child in the MVA has multiple injuries to multiple parts of the body which will result in a widespread, potentially whole body inflammatory response

in the process of phagocytosis, which substance coats the target cell to increase contact of the immune cell with the target cell?

opsonin RATIONALE during adherence phase of phagocytosis, opsonins coat target cell

when caring for a pt with lung inflammation and low alveolar macrophage levels, the nurse identifies that which immune function will be decreased?

phagocytosis RATIONALE phagocytosis is a primary activity of macrophages, without the presence of alveolar macrophages, phagosytosis is reduced

which finding does the nurse expect when assessing the wound site of a patient who experienced a gunshot injury that resulted in a loss of function at the site?

scar tissue RATIONALE scar tissue does not act like the tissue it replaces, function is lost in area.

which action takes place during the third stage of inflammation if there is permanent tissue damage that cannot be replaced? Select all that apply

scar tissue develops new blood vessels grow RATIONALE in the third stage of inflammation WBC's cause scar tissue to form and new blood vessels to grow which completes the healing process. pg.127

which assessment finding leads the nurse to suspect an inflammatory response when visually inspecting a patient's indwelling urinary catheter? select all that apply

swelling redness RATIONALE observable upon visual inspection

which cell type is responsible for secretion of histamine, serotonin, and kinins in the initial stage of inflammation, causing construction of small veins and dilation of arterioles in the area of injury?

tissue mast cells RATIONALE tissue mast cells present in injured tissue secrete histamine, serotonin, kinin and constrict small veins and dilate the arteriole which causes redness and warmth in the tissue. Basophils and neutrophils play a significant role in the second stage of inflammation. There is excess production of neutrophils, resulting in cellular exudates in the form of pus. Macrophages play a major role in the first stage of inflammatory response they are present in the place of injured tissues and secrete several cytokines. This triggers the response of the bone marrow to produce white blood cells