Chapter 6 Inflammation and Innate Immunity
A client's laboratory results indicate an increase in tumor necrosis factor α, interleukin 6, and prostaglandin. Which condition does the nurse expect to find in the client? 1 Cachexia 2 Hemophilia Incorrect3 Chemotaxis 4 Gram-positive bacterial infection
An increase in tumor necrosis factor α causes muscular wasting and results in cachexia. Chemotaxis, or the attraction of leukocytes to the site of infection, is an effect of interleukin 1, not interleukin 6. Gram-positive bacterial infection has no relationship to TNF α or interleukin 6.
A client with arthritis has severe inflammation in the knee, along with fever and anxiety. During the follow-up visit, the nurse finds that the client still has inflammation and swelling in the knee, but the fever and anxiety have subsided. Which medication does the nurse anticipate finding in the client's prescription? 1 Aspirin 2 Diazepam (Valium) 3 Acetaminophen (Tylenol) 4 Hydromorphone (Dilaudid)
Aspirin is a non-steroidal anti-inflammatory medication that reduces prostaglandin synthesis and reduces inflammation. Therefore, prescribing aspirin will be beneficial for the client since the client still has inflammation and swelling in the knee. Diazepam (Valium) is an anxiolytic medication that helps to reduce the symptoms of anxiety; it is not needed since the anxiety has subsided. Acetaminophen (Tylenol) is an analgesic and a fever reducer, but is not a non-steroidal anti-inflammatory medication, so it would not be beneficial since the fever has subsided. Hydromorphone (Dilaudid) is an opioid analgesic, but does not have anti-inflammatory properties to help with the swelling and inflammation that are still present.
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.
Consequences of hyperglycemia also include suppression of macrophages and increased risk for wound infection. Changes in glucose metabolism do not increase mast cell degranulation. Insulin deficiency does not suppress cell-mediated immunity. Diabetes mellitus is associated with impaired circulation that contributes to tissue ischemia, not bleeding.
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
Diapedesis is the process in which a leukocyte moves between endothelial cells to enter the tissues. Fusion of a lysosome with a phagosome occurs during phagocytosis after the phagocyte has entered the tissue. Both leukocytes and endothelial cells begin expressing molecules (selectins and integrins) that increase adhesion, or stickiness, causing the leukocytes to adhere more avidly to the endothelial cells in the walls of the capillaries and venules in a process called margination. Phagocytosis is the process by which a phagocyte engulfs a microorganism or other substance.
During wound healing a client develops contracture of scar tissue. Which problems should the nurse monitor for in this client? Select all that apply. 1 Dehiscence 2 Tissue proliferation 3 Impaired blood flow 4 Granuloma formation 5 Limited movement at joints
Excessive wound contraction at a joint can inhibit movement, and internal contractures can reduce blood flow to an area. Dehiscence is the opening of a sutured wound. Tissue proliferation is involved in healthy wound healing. Granuloma formation occurs with chronic inflammation and is not associated with wound contracture.
When should the nurse chart that the client has fibrinous exudate?
Fibrinous exudate is thick and sticky, because it contains large amounts of fibrin. Hemorrhagic exudate is reddish, because it contains numerous red blood cells. Serous exudate is watery, because it contains few cells and not much protein. Purulent exudate is whitish-yellow, because it contains many white blood cells and pus.
After reviewing the genetic reports of a client, the nurse suspects that the client has hereditary angioedema. Which finding supports the nurse's conclusion? 1 Decrease in clotting factors 2 Increase in tumor necrosis factor 3 Decrease in prostaglandin levels 4 Increase in plasma protein system
Genetic effects in C1 esterase inhibitor result in hereditary angioedema, which is associated with an increase in plasma protein system, such as excessive production of bradykinin. Decrease in clotting factors occurs in clients with hemophilia. Prostaglandins increase vascular permeability, but it is excessive production of bradykinin that is responsible for the increased vascular permeability in hereditary angioedema. Increase in tumor necrosis factor increases risk of muscle wasting syndrome.
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
If macrophages are unable to protect the host from tissue damage, the body attempts to wall off and isolate the infected area, thus forming a granuloma; this often occurs with chronic Listeria infection (listeriosis). Repaired tissues may be close to normal if damage is minor, no complications occur, and destroyed tissues are capable of regeneration. Only epithelial, hepatic, and bone marrow cells are capable of the complete mitotic regeneration of the normal tissue, known as compensatory hyperplasia. The Lectin pathway is one method to activate the complement system.
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
Increase in tumor necrosis factor-alpha causes cachexia and intravascular thrombosis. Hageman is a clotting factor; a decrease in Hageman factor increases the risk of bleeding. The white blood cell count increases in the client with an infection. High serum creatinine levels increase the risk of renal impairment.
A client with an upper respiratory tract infection has nasal congestion. During the assessment, the nurse finds that the client's blood pressure is 120/80 mm Hg and rate of respiration is 15 breaths/minute. The nurse should check the client's prescription for which category of medication to help with the congestion? 1 Diuretics 2 Antihistamines 3 Vitamin K supplements 4 Nonsteroidal antiinflammatory drugs
Infection and inflammation increase histamine levels and cause increased vessel permeability and swelling, causing nasal congestion in the client. Antihistamines block the binding of histamine to its receptors, which decreases inflammation and nasal congestion caused by infection. Therefore, the nurse would expect to find antihistamine medications in the client's prescription. Diuretics increase urine output and are used for fluid overload, not Infection. Vitamin K supplements help to treat clotting disorders, but not respiratory infection. Nonsteroidal antiinflammatory drugs help to alleviate pain, but do not reduce nasal congestion.
A client receiving antibiotics is experiencing perineal discomfort when urinating. Which microorganism should the nurse suspect is causing this client's problem?
Lactobacillus is a major vaginal flora commonly found in healthy women. It helps to produce hydrogen peroxide, lactic acid, and other molecules that help to prevent vaginal infection and urinary tract Infection caused by bacteria and yeast. Lactobacilli colonization diminishes upon prolonged use of antibiotics, which increases the risk of urologic and vaginal Infection, such as vaginosis. Salmonella typhi leads to typhoid fever. Clostridium difficile causes infection of the colon, pseudomembranous colitis. Pseudomonas aeruginosa is a normal flora on the skin. It produces toxin, which protects the skin against staphylococcal Infection.
Which laboratory test result will the nurse expect to find in a client with acute inflammation? 1 Leukocytosis 2 Erythrocytosis 3 Hypoproteinemia 4 Hyperbilirubinemia
Leukocytosis is one of the three primary systemic changes associated with acute inflammation. Hypoproteinemia impairs fibroblast proliferation and collagen synthesis. Erythrocytosis is production of too many red blood cells. Hyperbilirubinemia occurs from the destruction of too many red blood cells.
A client has an infection. Which cells provide long-term phagocytosis against infectious agents? 1 Mast cells 2 Neutrophils 3 Macrophages 4 Natural killer cells
Macrophages are better suited than neutrophils to long-term defense against infectious agents. Macrophages are involved in activation of the adaptive immune system and they have a longer life span since they can divide in the acidic inflammatory site, whereas neutrophils cannot. Mast cells are filled with granules and are involved in inflammation. Neutrophils are the first phagocytic cells at the site of infection; they have short-lived activity because they cannot divide and do not survive in an acidic environment. Natural killer cells do not have the capacity for phagocytosis but kill through other mechanisms.
A nurse is teaching about the functions of macrophages. Besides phagocytosis, which information should the nurse include in the teaching session? Select all that apply. 1 Activation of fibroblasts 2 Release of growth factors 3 Promotion of collagen formation 4 Stimulation of new blood vessel growth 5 Production of neutrophil-chemotactic factor
Macrophages orchestrate the wound healing process by cleaning up the site of injury by phagocytosis, promoting angiogenesis (new blood vessel growth), releasing cytokines and growth factors that promote epithelial cell division, activating fibroblasts, and promoting the synthesis of extracellular matrix and collagen formation. Neutrophils must release macrophage-chemotactic factors to attract macrophages to the area.
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
Monocytes produced by the bone marrow circulate in the blood, from which they enter tissue and mature into macrophages. Eosinophils, neutrophils, and leukocytes are mature cells.
A client injures the left leg. When will the nurse expect substantial numbers of neutrophils to arrive at the site of injury?Within 30 minutes 2 Within 1 to 2 hours Correct3 Within 6 to 12 hours 4 Within 24 to 48 hours
Neutrophils are the predominant phagocytes in the early inflammatory site, arriving within 6 to 12 hours after the initial injury. Macrophages enter the site after 24 hours or later, but usually arrive 3 to 7 days later.
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
Obesity increases the risk for dehiscence because adipose tissue is difficult to suture. Most wound dehiscence occurs 5 to 12 days after suturing. Age, race, and gender are not primary causes for poor wound healing. Prior surgeries are not risk factors for possible dehiscence.
Which process should the nurse include when teaching about how antibodies promote phagocytosis? 1 Diapedesis 2 Chemotaxis 3 Margination 4 Opsonization
Opsonization is the process of increasing the adherence between the phagocyte and the target cell. Both leukocytes and endothelial cells begin expressing molecules that increase adhesion, or stickiness, causing the leukocytes to adhere more avidly to the endothelial cells in the walls of the capillaries and venules, in a process called margination, or pavementing. Leukocyte-endothelial interactions lead to diapedesis, or emigration of the cells through the inter-endothelial junctions that have loosened in response to inflammatory mediators. Once inside the tissue, leukocytes undergo a process of directed migration, called chemotaxis, in which they are attracted to the inflammatory site by chemotactic factors.
The nurse is caring for a client with swelling and pain at the site of a wound. Which other physiological changes does the nurse expect to find? Select all that apply. 1 Increased redness 2 Increased blood flow 3 Decreased local temperature 4 Decreased hemoglobin levels 5 Increased blood glucose levels
Presence of swelling and pain at the site of the wound indicates that the client has inflammation at the wound site. Inflammation causes vasodilatation, which causes the site to appear red from increased blood flow. Inflammation does not impair hemoglobin formation. Inflammation is associated with an increase in temperature at the site of inflammation. Inflammation does not impair pancreatic functioning and does not cause hyperglycemia.
Which complication will the nurse monitor for in a client who has been prescribed long-term antibiotic therapy? 1 Increased risk of bleeding 2 Increased risk of hypertension 3 Increased risk of hypoglycemia 4 Increased risk of Candida albicans infection
Prolonged treatment with antibiotics alters the normal intestinal microbiome and causes overgrowth of yeast such as Candida albicans. Therefore, the nurse should plan care to address the potential for a Candida albicans infection. Antibiotics do not impair clotting, nor do they cause bleeding. Antibiotics do not cause vasoconstriction or hypertension. Antibiotics do not impair insulin production or cause hypoglycemia.
A client with an intestinal infection is receiving prolonged treatment with antibiotics. Which deficiencies are likely to occur in the client? Select all that apply.
Prolonged treatment with antibiotics inhibits the intestinal microbiome, which synthesizes vitamin K, thereby potentially resulting in vitamin K deficiency. Prolonged antibiotic use also inhibits the production of proteins called bacteriocins that inhibit pathogens. Opportunistic organisms are likely to increase in number when a client has been on antibiotics because these organisms thrive when the innate and acquired immune systems are compromised. Prolonged antibiotic use can cause an overgrowth of Candida albicans and Clostridium difficile because the normal gut flora that control these microorganisms may be affected by the antibiotics.
The nurse is caring for a client with arthritis who is scheduled for knee replacement surgery. After reviewing the client's medical history, the nurse finds that the client is at risk for delayed wound healing. Which medication did the nurse find in the client's medical history? 1 Steroid 2 Antihistamine 3 Vitamin C supplement 4 Potassium-sparing diuretic
Steroids inhibit migration of macrophages to the site of injury, and delay epithelialization and wound healing. Antihistamine medications do not impair platelet aggregation and do not impair wound healing. Vitamin C supplements enhance collagen formation and improve wound healing. Potassium-sparing diuretics will not impair epithelialization and do not impair wound healing.
After reviewing the history of a client with recurrent infection, the nurse finds that the client has impaired adaptive immunity. Which finding supports the nurse's conclusion? 1 The client has a T cell deficiency. 2 The client has a low platelet count. 3 The client has a low neutrophil count. 4 The client has an erythrocyte deficiency.
T lymphocytes form the third line of defense and play a major role in adaptive or acquired immunity. Therefore, deficiency of T cells impairs adaptive immunity. Platelets play a role in blood clotting. A decrease in the platelet count increases the risk of bleeding, but does not impair acquired immunity. Neutrophils form the second line of defense and a decrease in neutrophils impairs innate immunity. A decrease in erythrocyte levels increases the risk of anemia.
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
The primary activity of plasmin is to degrade fibrin polymers in clots; plasmin is a component of the fibrinolytic system. Plasmin does not remove dead antibodies. Kininases help degrade kinins, not plasmin. Histaminase degrades histamine, not plasmin.
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
Vitamins A and C are cofactors required for collagen synthesis. Protein, not vitamins A and C, is needed for fibroblast proliferation. Antineoplastic agents, not vitamins A and C, inhibit angiogenesis and slow cell division. Vitamins A and C do not increase fibrin deposition, which would impede healing.
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
Wound dehiscence usually is heralded by increased serous drainage from the wound and a client's perception that "something gave way." Wound infection is caused by the infiltration of pathogens into the wound. A keloid is a raised scar that extends beyond the original boundaries of the wound, invades surrounding tissue, and is likely to recur after surgical removal. Wound contraction, although necessary for healing, may become pathologic when contraction is excessive, resulting in a deformity or contracture of scar tissue.
The nurse is caring for a client after an accident. Which interventions should be included in the client's care plan to prevent contracture of tissue at the site of injury? Select all that apply.
the nurse should perform range-of-motion exercises and place the client in a proper position to prevent muscle damage and contracture of tissues. Providing adequate fluids helps to prevent dehydration. Encouraging the client to do guided imagery provides relaxation and reduces stress. Antiinflammatory medications provide pain relief, but do not prevent contracture of tissue at the site of injury.
An older adult client who had an accidental fall is admitted to the hospital. After reviewing the client's laboratory reports, the nurse believes the client is at risk for impaired wound healing. Which finding supports the nurse's conclusion? 1 High zinc levels 2 Increased oxygen diffusion 3 Increased manganese levels Correct4 High fasting blood glucose levels
Increased blood glucose levels impair epithelialization and impair wound healing. Zinc promotes wound healing, so high zinc levels would not put the client at risk for impaired wound healing. Manganese is required for collagen synthesis; manganese deficiency would impair wound healing. Reduced rather than increased oxygen diffusion impairs wound healing. Reduced oxygen diffusion caused by blood clots and the effects of diabetes lead to impaired wound healing.
While reviewing the medication history of a client, the nurse finds that the client is receiving long-term therapy with broad-spectrum antibiotics. Which complications does the nurse expect to find? Select all that apply. 1 Vaginosis 2 Sun sensitivity 3 Hyponatremia 4 Lactic acidosis 5 Pseudomembranous colitis
Prolonged treatment with broad-spectrum antibiotics diminishes the growth of normal vaginal and intestinal flora and increases the risk of vaginosis and pseudomembranous colitis. Long-term antibiotic use diminishes Lactobacillus colonization and leads to reduced production of lactic acid in the vagina. Prolonged treatment with broad-spectrum antibiotics does not cause hyponatremia or sun sensitivity.
While interacting with a client who was in a motor vehicle accident, the nurse suspects that the client is at risk for impaired wound healing. Which statement made by the client supports the nurse's suspicion?
Vitamin C increases collagen synthesis and enhances tissue healing. If the client does not like fruit, especially citrus, he or she may be less likely to get enough vitamin C and that can impair wound healing. Coffee contains caffeine and does not play a role in wound healing. Tylenol is an analgesic that helps to relieve pain and has no impact on wound healing. Bananas are a good source of potassium, but do not necessarily enhance wound healing.
When a client's complement system is stimulated, which processes will be activated? Select all that apply.
Activation of complement can cause cell lysis, mast cell degranulation, and opsonization. The lung produces and secretes a family of glycoproteins, collectins, to fight infection. A spectrum of nonpathogenic microorganisms, collectively called the normal microbiome, resides on the body's surfaces.