Pathophys ch 6 CAQs
A child with ill-fitting shoes developed a small blister that burst, releasing clear watery fluid. How should the school nurse document this type of exudate? 1 Serous 2 Purulent 3 Fibrinous 4 Hemorrhagic
1
A client breaks the first line of defense against infection. The next response the nurse should consider involves which mechanism? 1 Inflammation 2 Adaptive immunity 3 B lymphocyte production 4 T lymphocyte production
1
A client has a chronic infection of Listeria that the body cannot fight. Which pathophysiologic process should the nurse monitor for in this client? 1 Granuloma 2 Regeneration 3 Lectin pathway 4 Compensatory hyperplasia
1
A client has a low pH of urine and stomach contents. How should the nurse interpret these findings? 1 The first line of defense is working. 2 The third line of defense is working. 3 The fourth line of defense is working. 4 The second line of defense is working
1
A client has a low pH of urine and stomach contents. How should the nurse interpret these findings? 1 The first line of defense is working. 2 The third line of defense is working. 3 The fourth line of defense is working. 4 The second line of defense is working.
1
A client has an infection and the neutrophil level is elevated. Which function are the neutrophils providing for the client? 1 Phagocytosis 2 Antibody production 3 Antigen presentation 4 Immunologic memory
1
A client receiving antibiotics is experiencing perineal discomfort when urinating. Which microorganism should the nurse suspect is causing this client's problem? 1 Lactobacillus 2 Salmonella typhi 3 Clostridium difficile 4 Pseudomonas aeruginosa
1
A nurse is teaching about examples of granulocytes. Which cellular class should the nurse include? 1 Basophils 2 Monocytes 3 T lymphocytes 4 Natural killer cells
1
A nurse is teaching about the role of C3b. Which information should the nurse include? 1 Opsonin 2 Anaphylatoxin 3 Chemotactic factor 4 Membrane attack complex
1
How should a nurse support a hospitalized client's first line of defense against microorganisms? 1 Turn frequently 2 Administer antibiotics 3 Monitor body temperature 4 Educate about immunizations
1
When should the nurse document that the client has hemorrhagic exudate? 1 When reddish exudate, containing numerous red blood cells, occurs 2 When watery exudate, containing few cells and not much protein, occurs 3 When thick, clotted exudate, containing many plasma proteins, occurs 4 When whitish-yellow exudate, containing many leukocytes and bacteria, occurs
1
Which cytokine deficiency does the nurse suspect is causing delayed wound healing in a client? 1 Interleukin 6 2 Interleukin 10 3 Interferon alpha 4 Interferon gamma
1
Which laboratory test result will the nurse expect to find in a client with acute inflammation? 1 Leukocytosis 2 Erythrocytosis 3 Hypoproteinemia 4 Hyperbilirubinemia
1
Which information indicates the nurse has a correct understanding of bradykinin? Select all that apply. 1 Bradykinin can induce pain. 2 Bradykinin activates the clotting system. 3 Bradykinin increases vascular permeability. 4 Bradykinin causes smooth muscle cell contraction. 5 Bradykinin causes vasoconstriction of blood vessels.
1, 3, 4
While planning care for a client with inflammation, the nurse recalls that vasodilation and increased vascular permeability include which benefits? Select all that apply. 1 They dilute bacterial toxins. 2 They stimulate differentiation of antibodies. 3 They transport neutrophils to the area of injury. 4 They bring macrophage cells to the area of injury. 5 They reduce heat produced by chemical mediators.
1, 3, 4
Which assessment findings are classic for a client with inflammation of the knee? Select all that apply. 1 Painful knee 2 Pallor of the knee 3 Warmth of the knee 4 Swelling of the knee 5 Loss of knee movement
1, 3, 4, 5
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. 1 Stops bleeding 2 Initiates cell lysis 3 Inhibits mast cells degranulation 4 Prevents the spread of infection 5 Releases prostaglandins from platelets 6 Provides a framework for future healing
1, 4, 6
A nurse observes warmth and redness of the client's skin during inflammation. Which processes causes these changes? Select all that apply. 1 Vasodilation 2 Phagocytosis 3 Vasoconstriction 4 Neutrophil chemotaxis 5 Increased vascular permeability
1, 5
Which body fluids and secretions contain lysozymes that protect the client from invasion of gram-positive bacteria? Select all that apply. 1 Tears 2 Saliva 3 Mucus 4 Perspiration 5 Sebaceous glands
1,2, 4
Which assessment findings are classic for a client with inflammation of the knee? Select all that apply. Correct 1 Painful knee 2 Pallor of the knee Correct 3 Warmth of the knee Correct 4 Swelling of the knee Correct 5 Loss of knee movement
1,3,4,5
Which information from the staff indicates effective teaching by the nurse for the first line of defenses against disease? Select all that apply. 1 Intact skin 2 Phagocytes 3 T lymphocytes 4 B lymphocytes 5 Mucous membranes 6 Low skin temperature
1,5,6
A client is in the later stages of inflammation. The client's mast cells release leukotrienes that perform which function? 1 Opsonize bacteria 2 Increase vascular permeability 3 Activate the complement cascade 4 Attract neutrophils and eosinophils
2
A client states that there was a lot of drainage from the wound and it felt like "something gave way." What does the nurse expect the client is experiencing? 1 Keloid 2 Dehiscence 3 Wound infection 4 Impaired contraction
2
A client's immune system activates interferons. Which type of organism should the nurse suspect is causing this reaction? 1 Fungi 2 Viruses 3 Protozoa 4 Parasites
2
A nurse is asked by a coworker what an immature macrophage is called. How should the nurse respond? 1 A leukocyte 2 A monocyte 3 A neutrophil 4 An eosinophil
2
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? 1 Fusion 2 Diapedesis 3 Margination 4 Phagocytosis
2
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? 1 Dehiscence 2 Epithelialization 3 Scar tissue remodeling 4 Mast cell degranulation
2
An older adult client had a myocardial infarction yesterday. The client asks, "I understand that part of my heart muscle is dead, but will it grow back?" What is the best response by the nurse? 1 "Yes, but it may take longer because you are older." Correct2 "No, but it will heal by forming a scar where the heart muscle died." 3 "Yes, but you should eat protein and vitamin C to help the new cells grow." 4 "No, but a large scab will form, just like it does when you get a cut on your skin."
2
An older adult client had a myocardial infarction yesterday. The client asks, "I understand that part of my heart muscle is dead, but will it grow back?" What is the best response by the nurse? 1 "Yes, but it may take longer because you are older." 2 "No, but it will heal by forming a scar where the heart muscle died." 3 "Yes, but you should eat protein and vitamin C to help the new cells grow." 4 "No, but a large scab will form, just like it does when you get a cut on your skin."
2
The nurse anticipates that the client with which injury will be most at risk for developing chronic inflammation? 1 A paper cut 2 A wood splinter 3 A soft tissue bruise 4 A superficial incision
2
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? 1 Insulin deficiency suppresses cell-mediated immunity. 2 Hyperglycemia suppresses the activity of macrophages. 3 Impaired glucose metabolism increases mast cell degranulation. 4 Vascular changes with diabetes increase postoperative bleeding.
2
When should the nurse chart that the client has purulent exudate? 1 When reddish exudate, containing numerous red blood cells, occurs 2 When whitish-yellow exudate, containing many leukocytes, occurs 3 When watery exudate, containing few cells and not much protein, occurs 4 When thick, clotted exudate, containing many plasma proteins, occurs
2
Which information from the staff indicates successful teaching by the nurse for cytokines? 1 They include mast cells and basophils. 2 They include interleukins and interferons. 3 They are destructive enzymes contained in lysosomes. 4 They are regulatory chemicals secreted by endocrine glands
2
Which information from the staff indicates successful teaching by the nurse for cytokines? 1 They include mast cells and basophils. 2 They include interleukins and interferons. 3 They are destructive enzymes contained in lysosomes. 4 They are regulatory chemicals secreted by endocrine glands.
2
Which information indicates the nurse has a good understanding of chronic inflammation? 1 Chronic inflammation causes persistent bacterial infection, with local pockets of pus. 2 Chronic inflammation causes differentiation of macrophages into epithelioid and giant cells. 3 Chronic inflammation is an autoimmune process that is uncontrolled and causes repeated tissue damage. 4 Chronic inflammation is a large number of neutrophils in an area of active inflammation that has not yet healed.
2
Which findings will the nurse observe in a client with local inflammation of the eye? Select all that apply. 1 Pallor 2 Edema 3 Bruising 4 Redness 5 Gangrene
2, 4
A client has an inflammatory response. Upon assessment, the nurse finds edema in the client's foot. What caused the edema? 1 Leukocytosis 2 Cellular infiltration 3 Vascular permeability 4 Stimulation of nerve fibers
3
A client has an injury to the left leg. Which phagocytes will help the client in the early stage of inflammation? 1 Platelets 2 Eosinophils 3 Neutrophils 4 Macrophages
3
A client injures the left leg. When will the nurse expect substantial numbers of neutrophils to arrive at the site of injury? 1 Within 30 minutes 2 Within 1 to 2 hours 3 Within 6 to 12 hours 4 Within 24 to 48 hours
3
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? 1 More platelets are moving from your blood vessels into the lining of your throat. 2 The cells that line your throat are doing a healing process called regeneration. 3 Your blood vessels in the area have relaxed to allow more blood into the area to promote healing. 4 Chemical messengers from your inflamed throat put out a distress signal that brings more white blood cells to the area.
3
A nurse is asked about the primary function of plasmin in the body. What is the nurse's best response? 1 It degrades histamine. 2 It degrades bradykinin. 3 It degrades blood clots. 4 It degrades dead antibodies
3
A nurse is teaching about the clotting system. Which information should the nurse include? 1 The intrinsic pathway causes pain. 2 The intrinsic pathway causes cell lysis. 3 The extrinsic pathway is activated by tissue factor. 4 The extrinsic pathway is activated by Hageman factor
3
A nurse is teaching about the clotting system. Which information should the nurse include? 1 The intrinsic pathway causes pain. 2 The intrinsic pathway causes cell lysis. 3 The extrinsic pathway is activated by tissue factor. 4 The extrinsic pathway is activated by Hageman factor.
3
Several days before abdominal surgery, the client experiences nausea and vomiting and is unable to eat any food. The nurse closely monitors this client's wound healing after surgery. What is the rationale for the nurse's actions? 1 Hyperproteinemia leads to infection. 2 Emesis leads to excessive fibrin deposition. 3 Malnutrition causes reduced tensile strength. 4 Vitamin D causes poorly formed connective tissue
3
The nurse is inspecting a client's abdominal incision the day after surgery. What does the nurse expect to observe? 1 Remodeling 2 Granulation 3 Inflammation 4 Dehiscence
3
To help a client's wound heal, the nurse suggests eating foods high in vitamins A and C. What is the rationale for the nurse's action? 1 These vitamins inhibit angiogenesis. 2 These vitamins increase fibrin deposition. 3 These vitamins are required for collagen synthesis. 4 These vitamins are needed for fibroblast proliferation
3
When a client's mast cells degranulate, which substance is released? 1 Antibodies 2 Basophils 3 Histamine 4 Complement
3
When should the nurse chart that the client has fibrinous exudate? 1 When reddish exudate, containing numerous red blood cells, occurs 2 When whitish exudate, containing many leukocytes and bacteria, occurs 3 When thick, clotted exudate, from severe inflammation, occurs 4 When watery exudate, containing few cells and not much protein, occurs
3
When should the nurse chart that the client has serous exudate? 1 When reddish exudate, containing numerous red blood cells occurs 2 When whitish exudate, containing many leukocytes and bacteria occurs 3 When watery exudate, containing few cells and not much protein occurs 4 When thick, clotted exudate, containing many plasma proteins occurs
3
Which information indicates the nurse has a correct understanding of a cytokine that has some anti-inflammatory effects? 1 Interleukin-1 (IL-1) 2 Interleukin-6 (IL-6) 3 Interleukin-10 (IL-10) 4 Tumor necrosis factor alpha (TNF-alpha)
3
Which nursing assessment data increase the client's risk for wound dehiscence? 1 35-year-old man 2 25-year-old woman 3 5'3" tall with weight 189 lb 4 Has experienced several prior surgeries
3
Which term should the nurse use to describe a microorganism that does not infect people who have intact immune systems but does infect people who are immunosuppressed? 1 A giant cell microorganism 2 A cathelicidin microorganism 3 An opportunistic microorganism 4 An angiogenesis factor microorganism
3
Which term should the nurse use to describe the process of "gluing" bacteria with antibodies to promote phagocytosis of the microorganisms? 1 Margination 2 Engulfment 3 Opsonization 4 Endocytosis
3
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? 1 Inflammation is the necessary first stage of tissue healing. 2 When epithelialization has occurred, tissue healing is nearly complete. 3 Primary intention heals open wounds; rest and good nutrition will help it heal faster. 4 Proliferation and remodeling stages are necessary for a healing wound to be strong.
4
A client is having pain in an injured area. The nurse administers a nonsteroidal anti-inflammatory drug (NSAID). What is the rationale for the nurse's action? 1 NSAIDs promote the action of histamine. 2 NSAIDs block the action of interleukin-10. 3 NSAIDs promote the production of platelet. 4 NSAIDs block the synthesis of prostaglandins
4
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? 1 Remodeling 2 Primary intention 3 Classical pathway 4 Secondary intention
4
A nurse is asked what the difference is between monocytes and macrophages. How should the nurse respond? 1 Monocytes are phagocytic, macrophages release antibodies. 2 Monocytes release antibodies, macrophages are phagocytic. 3 Monocytes are found in tissues, macrophages circulate in the blood. 4 Monocytes circulate in the blood, macrophages are found in tissues
4
A nurse is asked what the difference is between monocytes and macrophages. How should the nurse respond? 1 Monocytes are phagocytic, macrophages release antibodies. 2 Monocytes release antibodies, macrophages are phagocytic. 3 Monocytes are found in tissues, macrophages circulate in the blood. 4 Monocytes circulate in the blood, macrophages are found in tissues.
4
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? 1 3 on a pain scale of 10 2 Skin next to incision slightly edematous 3 Pulse: 80 beats per minute, regular rhythm 4 Small amount of purulent exudate visible at distal end of incision
4
A nurse is discussing antimicrobial peptides, defensins, collectins, and mannose-binding lectin. What is the nurse describing? 1 Physical barriers 2 Normal microbiomes 3 Opportunistic microorganisms 4 Epithelial cell-derived chemicals
4
A woman presents with diminished colonization of Lactobacillus, which the primary healthcare provider diagnoses as vaginosis. Which finding will be typical when the nurse takes the history? 1 Diarrhea 2 Lack of vitamin K 3 Chronic back pain 4 Prolonged antibiotic treatment
4
How should the nurse describe the role of chemotaxis in inflammation to a coworker? 1 It releases histamine at the site of injury. 2 It leads to vascular changes at the site of injury. 3 It initiates the clotting cascade at the site of injury. 4 It causes migration of leukocytes to the site of injury
4
How should the nurse describe the role of chemotaxis in inflammation to a coworker? 1 It releases histamine at the site of injury. 2 It leads to vascular changes at the site of injury. 3 It initiates the clotting cascade at the site of injury. 4 It causes migration of leukocytes to the site of injury.
4
What is a client's first line of defense against infection? 1 Inflammation 2 Macrophages 3 Adaptive immunity 4 Epithelial cell-derived chemicals
4
Which information from the staff indicates effective teaching by the nurse for substances that act as opsonins? 1 Fibrin 2 Antigens 3 Histamine 4 Complement proteins
4
Which information indicates the nurse has a good understanding of pathogen-associated molecular patterns (PAMPs)? 1 PAMPs are an example of a major class of immunity cells that remove cellular debris. 2 PAMPs are an example of a major class of cell-surface pattern recognition receptors. 3 PAMPs are molecules that are expressed by infectious agents through products of cellular damage. 4 PAMPs are molecules that are expressed by infectious agents, either found on their surface or released as soluble molecules.
4
Which process in a client with a severe viral infection supports the nurse's suspicion that the client has risk of cachexia? 1 Decrease in Hageman factor 2 Decrease in white blood cell count 3 Increase in serum creatinine levels 4 Increase in tumor necrosis factor-alpha
4
Which process should the nurse include when teaching about how antibodies promote phagocytosis? 1 Diapedesis 2 Chemotaxis 3 Margination 4 Opsonization
4
Which order indicates the nurse has an accurate understanding of a client's defense mechanisms, from the first line of defense to the last?
1. Innate immunity 2. Inflammatory response 3. Adaptive immunity
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? 1 The complement system is a sequence of chemical messengers secreted by immune cells to help fight an infection. 2 The complement system is a set of proteins in the blood that help activate the body's inflammatory and immune response to infection. 3 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. 4 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
2
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? 1 The complement system is a sequence of chemical messengers secreted by immune cells to help fight an infection. 2 The complement system is a set of proteins in the blood that help activate the body's inflammatory and immune response to infection. 3 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. 4 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.
2
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? 1 Histamine 2 Antibodies 3 Leukotrienes 4 Prostaglandins
2
A client is experiencing acute inflammation and releases interleukin-1 (IL-1). Which piece of equipment should the nurse obtain to determine the effects of IL-1? 1 Stethoscope 2 Thermometer 3 Reflex hammer 4 Blood pressure cuff
2
A client is in phase II of wound healing. Which cells produce collagen during tissue healing? 1 Mast cells 2 Fibroblasts 3 Macrophages 4 Endothelial cells
2
