INFLAMMATION EAQs
Which action by the nurse is most helpful in treating a patient who is experiencing chills related to an infection? a) providing a light blanket b) encouraging a hot shower c) monitoring the patients body temperature every hour d) increasing the temperature on the thermostat in the patients room
A Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient. Encouraging a hot shower, monitoring temperature every hour, and turning up the thermostat in the patient's room are not the most helpful actions in treating a patient with chills.
The nurse notes redness around a patient's infiltrated IV site. Which physiologic event occurred related to the assessment finding? a) vasodilation b) change in pH c) shifting of fluid to interstitial spaces d) increased metabolism a the inflammatory site
A Inflammation causes a release of inflammatory mediators, which results in vasodilation, hyperemia, and increased capillary permeability. Vasodilation causes redness, or rubor, at the inflammatory site. A change in pH releases prostaglandins, causing dolor (pain) at the injury site. A shifting of fluid to interstitial spaces causes swelling. Increased metabolism at the inflammatory site results in calor.
The nurse is caring for a patient with multiple skin blisters on the chest after experiencing an adverse reaction to a medication. If the blisters rupture, which type of exudate will likely be present? a) serous b) fibrinous c) hemorrhagic d) serosanguineous
A Skin blisters result in an outpouring of fluid and produce serous exudate. Serous fluid exudate is generally seen in the early stages of inflammation. Fibrinous exudate is seen in surgical drain tubing. Hemorrhagic exudate is seen if a patient is bleeding after surgery. Serosanguineous exudate is seen in surgical drain fluid.
Which function does the complement system serve during an immune response? a) cellular lysis b) promoting clot formation c) decrease in vascular permeability d) cleaning the injured area before healing
A The complement system causes cellular lysis by creating holes in the cell membranes, causing those cells to rupture. The complement system increases vascular permeability. Thromboxane promotes clot formation during healing. Macrophages clean the injured area before healing.
Which term refers to the directional migration of white blood cells to the site of a cellular injury? a) cell lysis b) chemotaxis c) shift to the left d) chemical mediation
B Chemotaxis refers to the directional migration of white blood cells to an injury site. Cell lysis refers to cell rupture, leading to cell death. Chemical mediation describes the mediation of the inflammatory response by a variety of chemical mediators. A shift to the left refers to the presence of band neutrophils, which is an early sign of inflammation.
Which type of exudate will the nurse likely observe in a patient with diffuse inflammation in connective tissue? a) serous b) purulent c) fibrinous d) hemorrhagic
B Diffuse inflammation in connective tissue is called cellulitis; this condition produces purulent exudate. Serous exudate is observed in pleural effusion. Fibrinous exudate is seen in surgical drain tubing. Hemorrhagic exudate is seen in hematoma.
The nurse examines an IV site and determines that inflammation is present. Which assessment findings led the nurse to this conclusion? Select all that apply. a) ulcers at the site b) swelling of the site c) black discoloration d) redoes at the site e) reports of pain at the site
B D E Signs of inflammation are pain, swelling, and redness. Pain is caused by the change in pH, nerve stimulation by chemicals, and pressure from fluid exudate. Swelling is caused by fluid shift to interstitial spaces and accumulation of fluid exudate. Redness is a result of hyperemia from vasodilation. Blackish discoloration and ulcers are not indicative of inflammation.
The nurse evaluates wound healing for a patient with an arm laceration. The nurse recalls that which deficiency may cause insufficient collagen production by fibroblasts? a) zinc deficiency b) protein deficiency c) vitamin B deficiency d) vitamin C deficiency
D Vitamin C is needed for capillary synthesis and collagen production by fibroblasts. Zinc deficiency impairs epithelialization in the wound-healing process. Protein deficiency decreases the supply of amino acids for tissue repair. If a vitamin B deficiency develops, a disruption of protein, fat, and carbohydrate metabolism will occur.
The nurse reviews white blood cell (WBC) count laboratory results from four patients. Which patient's data indicates a "shift to the left?" Patient A - Absence of eosinophils Patient B - increased monocyte count Patient C - Decreased number of lymphocytes Patient D - presence of band neutrophils
Patient: D To keep up with the demand for neutrophils, the bone marrow releases more neutrophils into circulation. This results in a high WBC count, especially the neutrophil count. Sometimes the demand for neutrophils increases to the extent that the bone marrow releases immature forms of neutrophils (bands) into circulation. This increased number of band neutrophils in circulation is called a shift to the left. It is common in patients with acute bacterial infections. Increased monocyte counts, decreased numbers of lymphocytes, and an absence of eosinophils are not referred to as a "shift to the left."
The nurse provides care for a patient with a surgical wound and identifies that which vitamin will accelerate epithelialization? a) vitamin A b) vitamin C c) vitamin D d) B-complex vitamins
A Vitamin A accelerates epithelialization by combining with the collagen shields of the skin. Vitamin C helps in the synthesis of collagen and new capillaries. Vitamin D facilitates calcium absorption. B-complex vitamins act as coenzymes.
A patient is hospitalized with a chronic heel ulcer. The nurse identifies which systemic manifestations of inflammation? Select all that apply. a) Temperature of 102.2°F (39.0°C) b) Heart rate 116 beats/min c) Elevated serum protein levels d) Nausea and anorexia e) White blood cell (WBC) count 8,000/μL with a shift to the right
A B D Systemic manifestations of inflammation include an increased WBC count with a shift to the left (not the right), malaise, nausea and anorexia, increased pulse and respiratory rate, and fever. Normal vital sign ranges are as follows: temperature 97.6°F to 99.6°F (36.4°C to 37.6°C); respiratory rate 12 to 20 breaths/min; heart rate 60 to 100 beats/min. The normal WBC range is usually between 4,000 and 11,000 per microliter of blood. Elevated serum protein levels do not indicate inflammation.
The nurse discusses the beneficial aspects of fever with a group of nursing students and will include which information? Select all that apply. a) increased proliferation of t cells b) increased release of epinephrine c) enhancement of interferon activity d) increased killing of microorganisms e) impairment of the temperature control center
A C D Fever has several beneficial outcomes, including increased killing of microorganisms, increased proliferation of T cells, and enhancement of interferon activity. The increased release of epinephrine increases the metabolic rate and is involved in the development of fever. When a fever becomes too high, the temperature control center is impaired.
The nurse develops a plan of care for a patient with a soft tissue injury to the arm. Which nursing intervention is included in the plan? a) perform range of motion exercises on the arm to promote circulation b) elevate the arm above the level of the heart to reduce pain c) avoid compression bandages to the arm to minimize impairment of the nerves d) apply heart to the arm for the first 24 hours to promote healing
B An injured extremity may become engorged with blood. Elevation of the injured extremity above the level of the heart helps to reduce pain associated with swelling by increasing the venous and lymphatic return. Compression helps to reduce vasodilation and edema. However, distal pulses should be assessed before and after a compression bandage is applied to evaluate whether the extremity has compromised circulation. If the circulation is not compromised, a compression bandage can be used. The injured extremity should be immobilized and allowed to rest because immobilization promotes healing by decreasing the metabolic needs of the patient. At the time of initial trauma, cold fomentation should be used to promote vasoconstriction and decrease pain, swelling, and congestion. Heat may be used 24 to 48 hours after injury to promote healing by increasing circulation at the inflamed site.
Which cells arrive first at the site of injury during the inflammatory response? a) monocytes b) neutrophils c) lymphocytes d) macrophages
B Inflammatory response is a sequential reaction to cell injury. Neutrophils are the first leukocytes to arrive at the injury site. They usually reach the site of injury within 6 to 12 hours. They engulf bacteria, other foreign material, and damaged cells. Monocytes are the second type of phagocytic cells that migrate from circulating blood. They usually arrive at the site within three to seven days after the onset of inflammation. Lymphocytes arrive later at the site of injury. Their primary role is related to humoral and cell-mediated immunity. On entering the tissue spaces, monocytes transform into macrophages. Together with the tissue macrophages, these macrophages assist in phagocytosis of the inflammatory debris.
The nurse identifies that a hospitalized patient is at a high risk for the development of pressure ulcers. Which intervention does the nurse include in the plan of care to reduce the risk? a) encourage increase intake of juices b) reposition the patient every hour c) massage bony prominences once per shift d) clean the skin area once per day with hydrogen peroxide
B Repositioning the patient helps to prevent pressure ulcers. Repositioning time schedules and frequency should be based on risk factors, patient's overall condition, and type of mattress and support surface. For example, some high-risk patients may need to be turned and repositioned every hour. Massage is contraindicated if fragile skin is present. Although juices may contain nutrients that support healing, they do not reduce pressure ulcer risk. Hydrogen peroxide is cytotoxic, so its use is discouraged.
A patient with an inflammation reports malaise, nausea, and anorexia. The nurse identifies that the manifestations are indicative of which type of response? a) local response b) systemic response c) infectious response d) acute inflammatory response
B The systemic response to inflammation includes the manifestations of a shift to the left in the white blood cell (WBC) count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in two to three weeks and usually leaves no residual damage.
Which systemic clinical manifestations does the nurse anticipate finding in a patient who has inflammation at an injury site? Select all that apply. a) Hematocrit 46% b) Body temperature of 101°F (38.3°C) c) Pulse rate of 120 beats/min d) White blood cell (WBC) count of 13,000/µL e) Respiratory rate of 10 breaths/min
B C D The clinical manifestations of inflammation at the injury site are increased pulse and respiratory rate, increased white blood cell count and body temperature, and anorexia. Normal vital sign ranges are as follows: temperature 97.6°F to 99.6°F (36.4°C to 37.6°C); respiratory rate 12 to 20 breaths/min; heart rate 60 to 100 beats/min. The normal WBC range is usually between 4,000 and 11,000 per microliter of blood. A pulse rate of 120 beats/min is higher than normal. The WBC count of 13,000/µL is higher than normal. Inflammation results in increased metabolism and therefore increases the body temperature above normal. The hematocrit value of 46% is normal; the normal range for hematocrit is approximately 45% to 52% for men and 37% to 48% for women. The respiratory rate of 10 breaths/min is decreased; inflammation is manifested by increased respiratory rate.
Which physiologic change is associated with fever during inflammatory conditions? a) increased blood flow rate b) decreased neutrophil action c) Increased proliferation of T cells d) suppressed activity of interferon
C Fever is mediated by a host macrophage product called endogenous pyrogen (EP) that stimulates the proliferation of T cells. Fever increases the action of neutrophils and promotes phagocytosis. Vasodilators increase blood flow rate. Fever increases destruction of microorganisms by enhancing the activity of interferon.
Which datum documented by the nurse concerning a pressure ulcer is subjective? a) edema b) discoloration c) reports of pain d) moderate purulent drainage
C Reports of pain are considered subjective because the nurse cannot measure and observe it beyond the patient's reports. Edema, discoloration, and purulent drainage are objective data.
The nurse provides postoperative care for a patient one day after a hernia repair procedure. The patient's assessment findings include incisional pain, a temperature of 99.2°F (37.3°C), slight redness at the incision margins, and 20 mL of serosanguinous fluid in the surgical drain. How does the nurse interpret the data? a) the abdominal incision is showing signs of an infection b) the patients abdominal hernia repair was not successful c) the patient is experiencing a normal inflammatory response d) the abdominal incision is showing signs of impending dehiscence
C The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function. Typical drainage from a surgical tube is serosanguineous; purulent drainage would indicate an infection. The response is normal, not a sign of infection or of impending dehiscence. The symptoms do not necessarily indicate the hernia repair was not successful.
The nurse caring for a patient with an ankle injury observes erythema and edema, along with serous fluid at the site of injury. Which stage of the inflammatory response is the patient exhibiting? a) healing b) cellular response c) vascular response d) formation of exudate
C The patient is exhibiting vascular response. The serous fluid is a result of the outpouring of fluid, seen in the early stages of inflammation. During cellular response, neutrophils and monocytes move from vascular circulation to the site of injury, and the site becomes purulent. The nature and quantity of exudate formation prior to healing depend on the severity of injury. When the wound heals, there are no signs of inflammation.
In the depicted complement cascade, which enzyme is a potent vasodilator that contributes to edema and increased blood flow? a) leukotrienes b) thromboxane c) prostaglandins d) arachidonic acid
C The complement system is an enzyme cascade that mediates the inflammatory response. Prostaglandins are potent vasodilators that lead to increased blood flow and edema. After cell injury, arachidonic acid is converted to prostaglandins. Thromboxane leads to brief vasoconstriction and clot formation. The slow-reacting substance of anaphylaxis is formed by leukotrienes. p. 158
The nurse suspects that a patient may be experiencing an acute bacterial infection based on which laboratory result? a) increased platelet count b) increased blood urea nitrogen c) increased number of band neutrophils d) increased number of segmented myelocytes
C When the demand for neutrophils increases to the extent that the bone marrow releases immature forms of neutrophils (bands) into circulation, this is called a shift to the left. It is common in patients with acute bacterial infections. The finding of an increased number of band neutrophils in circulation is called a shift to the left, which commonly is found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing, but they are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.
A patient in an ambulatory care setting is prescribed a splint as treatment for a wrist fracture. Which nursing intervention is the priority? a) providing education about splint management after discharge b) elevating the wrist above heart level c) providing cold application to the wrist d) assessing distal pulses and capillary refill
D Assessing distal pulses and capillary refill after application of compression, cast, or splint is essential to evaluating for indications of compromised circulation (e.g., pale color of skin, loss of feeling). Swelling can occur within the closed space of a device and compromise circulation. Providing education is important but is not the priority. Elevating the injured extremity above the level of the heart reduces the edema at the inflammatory site by increasing venous and lymphatic return. Cold application is appropriate at the time of initial trauma to promote vasoconstriction and decrease edema, pain, and congestion from increased metabolism in the area of inflammation.
A patient presents with a runny nose associated with an upper respiratory tract infection. Which type of inflammatory exudate does the nurse expect to assess? a) purulent b) fibrinous c) serosanguinous d) catarrhal
D Catarrhal exudate is found in tissues where cells produce mucus; the inflammatory response accelerates mucus production. Purulent exudate occurs if a patient has a furuncle (boil), abscess, or cellulitis (diffuse inflammation in connective tissue). Fibrinous exudate occurs with increasing vascular permeability and fibrinogen leakage into interstitial spaces; examples include adhesions and venous injuries. Serosanguinous exudate may be found during the midpoint in healing after surgery or tissue injury; an example is surgical drain fluid.
A patient being treated for a large pressure ulcer on the heel reports new inflammation in the surrounding subcutaneous tissue. Which term describes the condition the patient is experiencing? a) sepsis b) keloid c) fistula d) cellulitis
D Cellulitis can occur due to untreated pressure ulcers and involves the spreading of inflammation to the subcutaneous (connective) tissue. Sepsis occurs when an infection spreads to the bloodstream. A keloid is a permanent protrusion of scar tissue beyond the edges of the wound or injury. Fistulas are abnormal passages that may occur secondary to a wound.
When a patient takes prednisone for rheumatoid arthritis, which laboratory result does the nurse expect to find? a) increase prothrombin time b) increased red blood cell count c) decreased serum protein levels d) decreased white blood cell count
D Prednisone is a corticosteroid drug that interferes with the synthesis of lymphocytes, resulting in a decreased white blood cell count. Prednisone does not interfere with prothrombin time. Prednisone does not increase red blood cell count because it does not stimulate erythropoiesis. Serum protein levels are not affected by prednisone.
The nurse pays close attention to which most common site for pressure ulcers when assessing a patient? a) heels b) ankles c) elbows d) sacrum
D Pressure ulcers generally occur over bony prominences; the sacrum is the most common site, followed by the heels. Elbows and ankles are less susceptible to pressure ulcers.
The nurse assesses the fluid found in a patient's surgical drain. The nurse describes the inflammatory exudate as serosanguinous based on which characteristic? a) presence of mucus b) gelatinous ribbons c) liquefied dead cells d) semi clear pink appearance
D Serosanguineous inflammatory exudate is composed of red blood cells and will resemble semiclear pink exudate. Catarrhal exudate contains mucus. Fibrinous exudate looks like gelatinous ribbons. Purulent exudate contains liquefied dead cells.
Which type of inflammatory exudate results from the rupture or necrosis of blood vessel walls? a) serous b) purulent c) fibrinous d) hemorrhagic
D The products of inflammation are known as inflammatory exudates. Exudates may ooze from the cuts or areas of inflammation. Hemorrhagic exudates result from rupture or necrosis of blood vessel walls during events such as hematoma, bleeding after surgery, or tissue trauma. Serous exudates result from an outpouring of fluid, seen in early stages of inflammation. Purulent exudates are associated with a preponderance of escaped leukocytes. Fibrinous exudates are formed by the action of fibrin ferment acting upon fibrinogen or fibrin-forming substances in the presence of calcium salts.