Clinical Path Chapter 3

The most common forms of peptic ulcer are duodenal and gastric ulcers. What are the most common risk factors for peptic ulcer disease?

Helicobacter pylori (H. pylori)

The nurse is caring for a client who has developed facial swelling related to a hypersensitivity reaction to a medication. Which of these substances does the nurse recognize is implicated in causing this type of reaction?

Histamine

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 has contributed to this client's decline in health?

Immunologically mediated joint inflammation

A client has been diagnosed with rheumatoid arthritis (RA). What will the nurse tell the client about this disorder's etiology?

"Genetic predisposition is very likely."

The nurse is caring for a client who reports chronic joint pain. Which statement(s) by the client indicates that the client most likely has rheumatoid arthritis? (Select all that apply.)

"I have been so tired lately." "I have a low-grade fever on and off." "My joints feel warm to the touch." "I don't have much of an appetite."

The nurse is providing discharge instructions for a postoperative client. The nurse determines the teaching is effective when the client verbalizes which statement about wound healing?

"I will regain almost full-tensile strength of an unwounded skin at the end of 3 months."

The student nurse is removing sutures on client after abdominal surgery, and the wound begins to pull apart. The student asks the instructor, "Did I do something wrong?" The instructor reviews wound healing and replies:

"Maybe the wound edges were not close enough together to allow epithelialization of the wound to occur."

Which digestive enzyme breaks down carbohydrates during acute pancreatitis?

Amylase

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 suggests the client is now within normal range.

4000 to 10,000 cells/μL

Which client likely faces the greatest risk of a gastrointestinal bleed?

A client who takes aspirin with each meal to control symptoms of osteoarthritis

When assessing the client with acute pancreatitis, which of these diagnostic tests—consistent with the disease— does the nurse anticipate will be altered?

Amylase and lipase

Which condition is an example of wound healing by secondary intention?

An infected burn of the arm

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

Acute gastritis

A client with a severe burn injury is treated at a burn center. After the client's airway, breathing, and circulation are stabilized, what is the nurse's priority of care?

Administering intravenous fluids to replace lost water and sodium

A child is experiencing frequent vomiting over the past 24 hours. What site in the neurologic system is responsible for vomiting?

Chemoreceptor trigger zone

Crohn disease is recognized by sharply demarcated, granulomatous lesions that are surrounded by normal-appearing mucosal tissue. The nurse recognizes these lesions to be defined by which description?

Cobblestone

A client underwent an open cholecystectomy 2 days ago, and the incision is now in the proliferative phase of healing. What is the dominant cellular process that characterizes this phase of the client's healing?

Collagen secretion by fibroblasts

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

A young man presents reporting diarrhea, fecal urgency, and weight loss. His stool is light-colored and malodorous, and it tends to float and be difficult to flush. He has also noted tender, red bumps on his shins and reports pain and stiffness in his elbows and knees. Sigmoidoscopy reveals discontinuous, granulomatous lesions; no blood is detected in his stool. Which diagnosis would his care team first suspect?

Crohn disease

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

Eradicating Helicobacter pylori (H. pylori)

Which response by the nurse answers a client's question regarding the most common objective sign of systemic inflammation during the acute-phase response?

Fever

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

Fibroblasts secrete collagen for wound healing.

A client asks the nurse why a scar developed after an injury. Which response by the nurse is most accurate?

Fibrous tissue

A client comes in with a mild sunburn. Which term best describes the sunburn?

First-degree burn

Crohn disease has a distinguishing pattern in the gastrointestinal (GI) tract. The surface has granulomatous lesions surrounded by normal-appearing mucosal tissue. A complication of the pattern includes:

Fistula formation

In clients with acute diarrhea, many require no treatment. However, the nurse knows the priority assessment in all clients with diarrhea is:

Fluid and electrolyte status

Crohn disease is treated by several measures. Treatment with sulfasalazine will focus on which aspect of this disease?

Inflammatory suppression

What laboratory markers are most commonly used to diagnose acute pancreatitis?

Lipase and amylase

What function does hyaluronic acid (a component of the extracellular matrix) perform in the body?

Lubricates joints and serves as a supportive structure in the extracellular space throughout

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 nurse is caring for a client with newly diagnosed systemic lupus erythematosus (SLE). Which over-the-counter medication does the nurse recognize is useful in treating inflammation, arthritis, and pleuritis?

Nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse caring for a postoperative client documents that the surgical incision is healing by:

Primary intention

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 nurse is caring for a client with rheumatoid arthritis (RA) who states she "caught" this from her mother. Which statement is the correct explanation of how this type of arthritis develops?

RA has an autoimmune and genetic predisposition.

A client is admitted to the hospital with first- and second-degree burns. Which assessment findings are associated with first-degree burns? Select all that apply.

Red or pink Painful

The nurse would identify the presence of granulation tissue at a wound site by which characteristic?

Red, moist tissue

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

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

Rubor, swelling, and pain

A client has a watery fluid leaking from a site of inflammation. The nurse would document this type of exudate as:

Serous

When caring for a client with a wound that is healing by primary intention, the nurse recognizes which characterization best describes 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 red 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 considers 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

Which clinical manifestation would lead the health care provider to diagnose the sunburn as severe?

There is blistering of the skin and associated fever and chills

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.

A client calls the clinic and tells the nurse she is concerned because her husband has developed shingles. She asks the nurse if he is contagious. The best response would be that herpes zoster (shingles) is:

contagious and can be transmitted to nonimmune contacts.

The surgeon has documented that a client is developing "proud flesh" at the postoperative wound site. The nurse recognizes this as:

excessive granulation tissue.

A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as a/an:

increase in circulating neutrophils.

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

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 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