Chapter 3 Inflammation and Tissue Repair

Crohn disease not only affects adults but also can occur in children. The nurse assesses for which major manifestation in children with Crohn disease?

Malnutrition

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."

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 had a total hip replacement. The nurse notices the surgical incision is splitting at both ends and there is cloudy, yellow exudate. Which statement is documented in the electronic health record?

"Wound dehiscence is noted at both ends of the surgical wound with cloudy, yellow exudate."

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 suggest the client is now within normal range.

4000 to 10000 cells/ul

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 she often takes aspirin for pain. The nurse should suspect what diagnosis.

Acute gastritis

Which digestive enzyme break down carbohydrates during acute pancreatitis?

Amylase

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

Which client's cellular injury may result in regrowth/regeneration of the injured cells as long as the conditions are right for the proper mitotic division to promote regeneration? Select all that apply.

Client with skin cells affected by a mild sunburn that resulted in shedding of epithelial cells Client with cells on the roof of the mouth that were burned from a hot liquid Client with cells lining the gastrointestinal tract following a severe bout of diarrhea from food poisoning Client whose liver cells (hepatocytes) have been damaged by alcohol toxicity

A nurse reading a sigmoidoscopy report notes that a client was found to have skip lesions. The nurse interprets this as an indication of:

Crohn disease

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

Edema

Pharmacological treatment for peptic ulcers has changed over the past several decades. The nurse knows that the goal for pharmacological treatment is focused on:

Eradicating helicobacter pylori (H. Pylori)

Which body response to an acute inflammation will the nurse assess if the client is experiencing a systemic response?

Fever and tachycardia

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

Fibroblasts secrete collagen for wound healing

A nurse is teaching a client diagnosed with Crohn disease about potential complications. The most appropriate information for the nurse to include would be:

Fistula formation

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 the contributed to this client's decline in health?

Immunologically mediated joint inflammation

The nurse is caring for a client with an accumulation of 2.5 cm of darkened tissue scar over the area of a 3-mm injury. How does the nurse correctly document this finding in the medical record?

Keloid

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

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.

While reviewing the phases of wound healing, the students note that the injury are the:

Neutrophils

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

No definitive test exists

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

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:

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

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

Rubor, swelling, and pain

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 describe this type of wound?

Surgical incision

Following hip replacement surgery, the client has had many weeks of physical therapy. Upon assessing the wound, it is still read and draining thick, green, odoriferous secretions. The client has limited range-of-motion and is constantly reporting pain. The physician explains that the hip device needs to be removed. Why is removal required?

The body consider the hip replacement device a foreign body and an infection has developed around the joint.

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

Why is H. Pylori infection so difficult to treat?

The infection is deep in the stomach mucosa

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 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.

Which digestive enzyme breaks down carbohydrates during acute pancreatitis?

amylase

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 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