مهمN3119 - INFLAMMATION
A patient presented to the emergency department of the hospital with a swollen, reddened, painful leg wound and has been diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) cellulitis. The patient's physician has ordered a complete blood count and white cell differential. Which of the following blood components would the physician most likely anticipate to be elevated?
Neutrophils Increased neutrophils are associated with inflammation in general and bacterial infections in particular. Platelets play a role in inflammation but their levels would not rise to the same extent as would neutrophils. Eosinophils are not strongly associated with bacterial infection and basophils would not increase to the same degree as neutrophils. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 50
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 Vasodilation of the arterioles and congestion of the capillary beds result in an increased pooling of blood leading to redness. The site would also have increased painful sensation and be warmer to touch. It would not result in an increase in bacterial load. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 53
A nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for:
Rubor, swelling, and pain The classic signs of inflammation are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). The remaining options are more characteristic of symptomatology resulting from circulatory dysfunction. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 53
A nurse educator is describing the way that cells involved in the inflammatory response find their way to the site of injury. Which description best reflects this physiologic mechanism?
"The process of chemotaxis is the process where cells wander through the tissue guided by secreted chemoattractants." Chemotaxis is the dynamic and energy-directed process of directed cell migration. Once leukocytes exit the capillary, they wander through the tissue guided by a gradient of secreted chemoattractant, bacterial and cellular debris, and protein fragments generated from activation of the complement system. Phagocytosis is the engulfment of foreign or infective material. Margination is the first step of the cellular stage and is a separate process from chemotaxis, which is the third step in the cellular response. Tissues do not store inflammatory cells. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 55
Which symptom indicates the next stage of a fever after a prodrome?
A chill The physiologic behaviors that occur during the development of fever can be divided into four successive stages: prodrome, chill, flush, and defervescence. The stages are successive. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 67
1m 26s A nurse is caring for a patient with fever of unknown origin (FUO). The nurse anticipates that the patient may have which of the following underlying conditions? Select all that apply.
1. Non-Hodgkin's lymphoma 2. Abscessed infection Underlying causes of FUO include malignancies, infections such as human immunodeficiency virus, tuberculosis, abscessed infections, and drug fever. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 67
Fever in infants and young children is not an uncommon event. Many trips to the pediatrician's office occur because of fever in children ages 1 day to 3 years. Which sign or symptom does not indicate fever in an infant?
Avid feeding Infants with fever may not necessarily appear ill. In infants younger than 3 months, a mild elevation in temperature (i.e., rectal temperature of 38°C [100.4°F]) can indicate serious infection that requires immediate medical attention. Signs of toxicity include lethargy, poor feeding, hypoventilation, poor tissue oxygenation, and cyanosis. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 68
Which risk factor is greatest in the older adult population who are experiencing a dysfunctional temperature regulator function?
Delayed initiation of appropriate treatment The elderly often have a lower baseline temperature (36.4°C [97.6°F]) than younger persons, and although their temperature increases during an infection, it may fail to reach a level that is equated with significant fever. The absence of fever may delay diagnosis and initiation of antimicrobial treatment. Absence of fever does not result in misdiagnosis. While the remaining options may occur, they are not the greatest risks for injury. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 68
A patient's body temperature has been documented as follows: 12 noon: 37.0°C; 6 pm: 37.5°C; 3 am: 36.0°C. Which of the following actions should the nurse take?
Document the temperature The nurse should document the temperature, as the temperature is within normal limits and a drop in temperature in the early morning hours is expected with the lowest occurring between 3:00 am and 6:00 am. Therefore, there is no need to contact the physician, retake the temperature, or offer the patient a warm blanket. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 63
The nurse is assessing a client for acute inflammation of a wound. For which of these symptoms of infection does the nurse assess?
Edema Cardinal signs of inflammation include rubor (redness), tumor (swelling or edema), calor (heat), dolor (pain) and functio laesa (loss of function). Tissue necrosis occurs with chronic inflammation. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 53
The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as:
Exudate containing white blood cells, protein, and tissue debris A purulent or suppurative exudate contains pus, which is composed of degraded white blood cells, proteins, and tissue debris. Fibrinous exudates contain large amounts of fibrinogen. Serous exudates are watery fluids low in protein. Hemorrhagic exudates occur when there is severe tissue injury that causes damage to blood vessels or when there is significant leakage of red cells Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 60
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 The most prominent observable systemic manifestations of inflammation during the acute-phase response is fever. Painful palpable nodes are commonly associated with a systemic inflammatory process; fever is more often recognized. Edema is a characteristic of a localized inflammation, while diarrhea is not generally recognized as a sign of inflammation unless specifically related to the GI system. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 63
Inflammation can be either local or systemic. What are the most prominent systemic manifestations of inflammation?
Fever, leukocytosis or leukopenia, and the acute phase response The most prominent systemic manifestations of inflammation include the acute phase response, alterations in white blood cell count (leukocytosis or leukopenia), and fever. A widening pulse pressure is not indicative of systemic inflammation, and thrombocytopenia is a hematologic disorder, not an indication of systemic inflammation. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 59
In which of the following patients with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation?
Injury at T2 Spinal cord injuries that transect the cord at T6 or above can sriously impair temperature regulation because the thermoregulatory centers in the hypothalmus can no longer control skin blood flow and sweating. T9, L4, and L1 injuries are below the level of T6 and do not impair the hypothalmus' ability to control skin blood flow and sweating. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 63
The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation?
Loss of function These signs are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). In the second century AD, the Greek physician Galen added a fifth cardinal sign, functio laesa (loss of function). Altered level of consciousness is not a cardinal sign of inflammation. Sepsis and fever are systemic signs of infection. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 53
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 Monocytes, which are precursors of the mononuclear phagocyte system, are often referred to as macrophages when they enter the tissues. These leukocytes play an important role in chronic inflammation and are also involved in the immune response by activating lymphocytes and by presenting antigens to T cells. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 52
A client is said to be in the chill stage of the fever process when the nurse does which of the following?
Observes piloerection on the skin During the second stage or chill, there is the uncomfortable sensation of being chilled and the onset of generalized shaking (rigors). Vasoconstriction and piloerection usually precede the onset of shivering. At this point, the skin is pale and covered with goose flesh. Sweating is an indication of the third stage or flushing. The other options are not descriptive of stages but rather interventions. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 67
The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis?
Sepsis In severe bacterial infections (sepsis), large quantities of microorganisms in the blood result in the production and release of enormous quantities of inflammatory cytokines and development of what is referred to as the systemic inflammatory response syndrome. Systemic inflammatory response syndrome results in generalized vasodilation, increased vascular permeability, intravascular fluid loss, myocardial depression, and fatal circulatory shock. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 63
A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the patient's temperature on admission and finds that it is 96.6°F. Which of the following describes how the nurse should interpret the finding?
The patien tmay be exhibiting a blunted or absent febrile response. The nurse should interpret the finding as a blunted or absence febrile response to the infection. It has been suggested that as many as 30% of older adults with serious infections present with absent or blunted febrile response, and this may delay diagnosis and initiation of antimicrobial treatment. Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 68
The nurse is assessing a client with diabetes and notes an area on the client's right foot as inflamed, necrotic, and eroded. The client states he accidentally slammed his foot in a door 2 weeks ago. The nurse would document this finding as a(n):
Ulceration Ulceration refers to a site of inflammation where an epithelial surface (e.g., skin or gastrointestinal epithelium) has become necrotic and eroded, often with associated subepithelial inflammation. Ulceration may occur as the result of traumatic injury to the epithelial surface (e.g., peptic ulcer) or because of vascular compromise (e.g., foot ulcers associated with diabetes).The other options do not present these manifestations Chapter 3: Inflammation, the Inflammatory Response, and Fever - Page 60