inflammation prep u
Which client will the nurse be assessing in relation to problems with thermoregulation?
66-year-old client with damage to the hypothalamus secondary to a cerebral vascular accident.
Which statement about natural killer (NK) cells is the best explanation of their function when reviewing laboratory work for a 10-year-old child?
"The primary job of natural killer (NK) cells is to hunt down and destroy foreign cells in the body."
The parents of a 2-year-old child ask the nurse why their toddler's wounds do not seem to heal as quickly as their older children. Which response by the nurse is most accurate?
"The younger child has an immature immune system with no experience with organisms."
Following an injury that resulted in a major wound, the client notes that on day 2, the wound looks a little different. The client also notes that if he just brushes the skin accidentally with a towel, it bleeds easily. The client asks why this happens. Which is the best response by the nurse?
"There is new granulation tissue forming that contains many newly developed, fragile capillary buds."
A client comes to the clinic following exposure to chicken pox. The client states he had chickenpox as a child but was worried about getting sick again. Which statement best explains humoral-mediated immunity to the client?
B lymphocytes (B cells) in the body produce antibodies to fight infections. Once exposed, the cells retain memory and are able to quickly fight off pathogens during re-exposure and prevent the disease from reoccurring.
When talking about the various types of granulocytes, which granule contains heparin, an anticoagulant?
Basophils.
Select the option that best describes the production of T lymphocytes.
Bone marrow → thymus → lymph nodes
When caring for a client with a deeply infected wound that has been slow to heal, the nurse recognizes which of these are considered inflammatory mediators present during wound healing? Select all that apply.
Complement Tumor necrosis alpha Vascular endothelial growth factor
Which leukocyte is correctly matched with its function within the body?
Eosinophil—allergic reaction
A client comes to the clinic with symptoms of fatigue, fever, severe joint pain, and headache. Based on these symptoms, the nurse anticipates which laboratory tests may be prescribed? Select all that apply.
Erythrocyte sedimentation rate (ESR) White blood cell count (WBC)
A nurse's hand-off reports states that the client has pyrexia. The nurse plans care for the client who has:
Fever
A client asks the nurse why a scar developed after an injury. Which response by the nurse is most accurate?
Fibrous tissue
A client with environmental allergies is experiencing respiratory inflammation. Which mediator causes vasodilation during the vascular stage of the inflammatory response?
Histamine
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
Which function is the main job of lymphocytes?
Immune reaction
While reviewing how tissue repairs itself after injury, the students note that it follows a certain pattern. Place the steps of the repair of tissue in their proper sequence of events.
Injury to connective tissue occurs. Fibroblasts migrate. Induction of fibroblast occurs and endothelial cells proliferate. Granulation tissue appears. Formation of a scar develops. Remodeling occurs with the reorganization of the fibrous tissue.
A nursing professor is teaching nursing students about the immune system. The instructor knows that teaching has been successful when a student correctly identifies which cell as being responsible for the activation of the immune system?
Macrophages
A nurse sends a blood sample to the lab for analysis. Assuming the sample is normal, the nurse anticipates which white blood cells (WBCs) will account for the highest percentage?
Neutrophils
Following an injury resulting in a small cut from a knife, the first cells to go to the area of the cut would be the:
Neutrophils
When a white blood cell with differential count reveals an acute infection, which statement is correct regarding the client's neutrophils?
Neutrophils are the first white blood cell to elevate in an acute infection.
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 diabetic client has injured his foot while walking barefoot on the lawn. On admission, which assessment finding would be considered a localized cardinal sign of acute inflammation?
Redness and edema at the injured site
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
The nurse notes the client has developed a systemic response of inflammation based on assessment findings. Which clinical manifestations support this diagnosis? Select all that apply.
Temperature of 100.9°F (38.3°C) Somnolence Generalized achiness
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.
The nurse is reviewing the complete blood count (CBC) and white blood cell (WBC) differential of a client admitted with lower right abdominal pain. Which laboratory results are the most important for the nurse to communicate to the health care provider?
White blood cells (WBCs) 18,500/µL (18.50 x 109/L)
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
removing dead or infected tissue to promote wound healing