ACUTE & CHRONIC I EXAM 1

which statement made by the client indicates understanding after teaching about measures to decrease the risk for antibiotic-resistant infections? select all that apply.

a) "i should wash my hands frequently." c) "i should avoid taking antibiotics to treat the common cold." e) "i should avoid taking antibiotics without asking the primary care provider."

which function of leukocytes is involved in the inflammation process? select all that apply.

a) destruction of bacteria & cellular debris. c) release of vasoactive amines during allergic reactions.

what accurately describes artificial passive acquired immunity? select all that apply.

a) gamma globulin injection. c) immediate effect, lasting a short time.

which change would the nurse assess for in a client who sustained ski injuries 3 days ago?

a) local edema. b) erythema.

which option is an example of actively acquired specific immunity? select all that apply.

a) recovery from measles. b) recovery from chickenpox. d) immunization with live or killed vaccines.

after noting 12 mm of induration at the site of a tuberculosis skin test (TST) in a client with no tuberculosis risk factors, which information would the nurse give the client?

the result is negative, and a follow-up is not needed.

a patient had who had abdominal surgery 3 months ago calls the clinic reporting severe abdominal pain and cramping, vomiting, and bloating. what would the nurse suspect is the most likely cause?

adhesion.

which statement indicates the meaning of "a shift to the left" when evaluating the white blood cell count differential?

increased immature neutrophils.

two days after delivery a client has a temperature of 101 F (38.3 C), general malaise, anorexia, and chills. which clinical finding would the nurse expect to identify on the client's laboratory report?

increased white blood cell (WBC) count.

what effect does the action of the complement system have on inflammation?

increases inflammatory responses of vascular permeability, chemotaxis, and phagocytosis.

which type of immunity is the result of contact with the antigen through infection and is the longest lasting type of immunity?

natural active acquired immunity.

when naloxone has been administered to a client with an opiate overdose, which action is most important for the nurse to take?

observe respiratory rate and depth.

which condition would the nurse suspect in a client with mumps who reports pain, inflammation, and swelling of the testes?

orchitis.

which action by the nurse is the priority when admitting a client who has a productive cough, fever, and chills, and reports having children at home with whooping cough (pertussis)?

place client on droplet precautions.

what is the main difference between healing by primary intention and healing by secondary intention?

presence of more granulation tissue in secondary healing resulting in a larger scar.

which nursing action is beneficial for the client who has pain due to muscle spasm?

providing heat compresses at the site.

the patient is admitted from home with a clean stage 2 pressure injury. what would the nurse expect to observe when doing a wound assessment?

red-pink wound bed, without slough.

what is the most important nursing intervention for the prevention and treatment of pressure injuries?

repositioning the patient frequently.

key interventions for treating initial soft tissue injury and resulting inflammation are remembered using the acronym RICE. what are the most important actions for the emergency department nurse to do for the patient with an ankle injury?

rest with immobility, apply a cold compress and/or a compression bandage, and elevate the ankle.

which communicable infection would a nurse in the pediatric clinic be concerned about after receiving a call from the mother of a 12-month-old infant who has had a fever, runny nose, cough, and white spots in the mouth for 3 days with a rash that started on the face and has now spread to the entire body?

rubeola.

during the healing phase of inflammation, which cells would be most likely to regenerate?

skin.

the patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see muscle. what stage of pressure injury would the nurse expect to see on admission?

stage 4.

which type of immunity is conferred when an 11-year-old boy who has stepped on a rusty nail is given tetanus immune globulin in the emergency department?

temporary passive acquired immunity.

In a patient with leukocytosis with a shift to the left, what would the nurse recognize as the cause?

the demand for neutrophils causes the release of immature neutrophils from the bone marrow.

what is a characteristic of chronic inflammation?

the injurious agent persists or repeatedly injures tissue.

which nutrients aid in capillary synthesis and collagen production by the fibroblasts in wound healing?

vitamin c.

a child in respiratory distress is admitted to the hospital and diagnosed with acute spasmodic laryngitis (spasmodic croup). at the time of discharge, which recommendation would the nurse make to the parent for handling another attack at home?

"place them near a cool-mist humidifier."

which response would a nurse give to a client with tuberculosis who takes a combination therapy with isoniazid, rifampin pyrazinamide, and streptomycin who makes the statement "i've never had to take so much medication for an infection before."

"the bacteria causing this infection are difficult to destroy."

which response would a nurse give when a client asks what to expect when beginning treatment for tuberculosis?

"therapy will occur over two phases."

which response would the nurse give when caring for a client with an upper respiratory infection who asks why the health care provider did not prescribe an antibiotic?

"upper respiratory infections are generally caused by viruses and would not be treated with antibiotics."

in which order do events occur in stage I of the inflammatory process?

1) blood vessel changes cause redness and tissue warmth. 2) increased blood flow causes swelling at the site of injury. 3) capillary leak causes pain. 4) edema from plasma leaking protects further injury. 5) cytokine is released to produce more white blood cells.

arrange the sequencing required to stimulate antibody-mediated immunity.

1)exposure of antigen. 2) antigen recognition. 3) sensitization. 4) antibody production. 5) antibody-antigen binding. 6) antigen elimination.

which patient is at the greatest risk for developing a pressure injury?

a 30 year old man who is comatose after a head injury.

which finding would the nurse identify as normal inflammation versus an infection when assessing a client's wound that was sutured 72 hours ago?

a slight red border around the wound.

which action describes the process of artificial active immunity?

antibodies are made after an antigen is injected into the body.

which type of immunity will clients acquire through immunizations with live or killed vaccines?

artificial active immunity.

what does the mechanism of chemotaxis accomplish?

attracts the accumulation of neutrophils and monocytes to an area of injury.

which one triggers humoral immunity? select all that apply.

b) atopic diseases. c) bacterial infection. d) anaphylactic shock.

which nursing interventions for a patient with a stage 4 sacral pressure injury are most appropriate to assign or delegate to a LPN/VN? select all that apply.

c) assist the patient to change positions at frequent intervals. e) measure the size (width, length, depth) of the pressure injury.

the nurse conducts an initial interview and would suspect the client has tuberculosis based on which clinical indicator? select all that apply.

c) hemoptysis. d) night sweats.

documentation indicates a patient with stage 3 pressure injury on their right hip. what would the nurse expect to observe when assessing the patients right hip?

deep crater through subcutaneous tissue to fascia.

a patient had a complicated vaginal hysterectomy. the student nurse provided perineal care after the patient had a bowel movement. the student nurse tells the nurse there was a lot of light-brown, smelly drainage seeping from the vaginal area. what complication would the nurse expect?

fistula formation.

which meal is most appropriate for a client with a large pressure injury?

grilled chicken, steamed spinach, and a side of orange slices.

when caring for patients, what is the most important precaution for preventing transmission of infection?

hand washing after touching fluids and secretions, removing gloves, and between patient contact.