Patho- Chapter 3

The route considered the most accurate to measure a core body temperature is:

rectal The rectal temperature is used as a measure of core temperature and is least invasive of all of these options.

What can the nurse tell a client about antipyretic drugs during fever?

"Antipyretics help to protect the body." Antipyretic drugs are given to alleviate the discomfort of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature. They are usually effective.

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.

4,000-10,000cells/μL A normal value of white blood cells would be 4000 to 10,000 cells/μL. In acute inflammatory conditions, the white blood cell count commonly increases from 15,000 to 20,000 cells/μL. The other results are abnormal.

A nurse is providing care for several clients on a neurological unit of a hospital. With which of the following clients would the nurse be justified in predicting a problem with thermoregulation?

A 66 year old male with damage to his thalamus secondary to a cerebral vascular accident. The thalamus is involved in the sensation and regulation of body temperature. Syphilis, a T8 fracture and damage to the cerebellum would be unlikely to manifest by difficulties with thermoregulation.

Which clients are showing manifestations of infection? Select all that apply.

A 75-year-old, temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue A 25-year-old, temperature 40°C (104°F), sweating, shivering, states generalized pain A 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis Explanation: An older adult with an infection may have a minimal rise in temperature, but exhibit changes in mental status, weakness, fatigue, and weight loss. An infant younger than three months may have a relatively mild fever, but a serious infection. An adult with a high fever will exhibit sweating and chills. Aches and pains may occur with shivering and the infectious illness. A client with a temperature within the normal range, exhibiting no other signs of change, is not considered to have an infection.

A client has been diagnosed with a fever of unknown cause. The nurse recognizes this as:

A prolonged fever that does not have an identified source A prolonged fever for which the cause is difficult to ascertain is often referred to as fever of unknown origin (FUO). FUO is defined as a temperature elevation of 38.3°C (101°F) or higher that is present for 3 weeks or longer. An FUO can occur in children or adults.

A client presents with an oral temperature of 101.7°F (38.7°C) and painful, swollen cervical lymph nodes. Laboratory results indicate neutrophilia with a shift to the left. Which diagnosis is most likely?

A severe bacterial infection Fever and painful, palpable lymph nodes are nonspecific inflammatory conditions; leukocytosis is also common but is a particular hallmark of bacterial infection. Neutrophilia also indicates a bacterial infection, whereas increased levels of other leukocytes would indicate other etiologies. The shift to the left—the presence of many immature neutrophils—indicates that the infection is severe, because the demand for neutrophils exceeds the supply of mature cells.

An 88 year old resident of a long term care home has been suffering from a three day onset of increasing shortness of breath and decreased oxygen saturation. At the hospital, an anterior-posterior chest X-ray and sputum culture and sensitivity has confirmed a diagnosis of bacterial pneumonia, yet the client's tympanic temperature has not exceeded 37.3°C (99.2°F). The health care team would recognize that which of the following phenomena likely underlies this situation?

An older adult's hypothalamus has diminished thermoregulatory ability. The hypothalamus in older adults is often less capable of thermoregulation than in younger clients. There are sometimes alterations in the release of endogenous pyrogens and deficits in vasoconstriction. While infections do often manifest with cognitive changes in older adults, this does not explain why fever is precluded.

Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?

Apply cooling blanket Conduction is the transfer of heat from one molecule to another. A nurse attempting to use conduction to lower a client's temperature should apply a cooling blanket, as this would conduct heat from the skin to the cool surface of the blanket.

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 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?

A client with a rising temperature is pale and has begun to shiver. The nurse reports that the client is in which phase of fever development?

Chill During the second phase or chill phase of fever development, the client's skin is pale; there is an onset of shivering, a rising temperature, and the sensation of being chilled. Therefore, the nurse should report that the client is in the second or chill phase of fever development.

A client diagnosed with bacterial pneumonia has an increase in the number of bands in the white blood cell count. Which is the priority action of the nurse?

Continuing to monitor the client's laboratory results; this is an expected finding in an acute infection. Neutrophilia is an increase in immature neutrophils (bands) seen in the peripheral blood. It is most commonly seen in acute infections and tissue injuries that promote the accelerated release of neutrophils and their precursors into the circulation.

The loss of heat from the body through the circulation of air currents is known as:

Convection Convection refers to heat transfer through the circulation of air currents, while radiation is the transfer of heat through air or a vacuum. Conduction is the direct transfer of heat from one molecule to another, and evaporation involves the use of body heat to convert water on the skin to water vapor.

A pregnant client comes to the clinic with symptoms of body aches, headache, and fatigue. A physical assessment reveals enlarged lymph nodes. A diagnosis of toxoplasmosis with chronic inflammation caused by a parasitic organism is determined. Which assessment findings would most likely also be present? Select all that apply.

Cysts due to granuloma formation Increase in eosinophil count Granulomatous inflammation is a distinctive pattern of chronic inflammation in which the macrophages form a capsule around insoluble materials that cannot be digested. Immune granulomas are caused by insoluble particles that are capable of inciting a cell-mediated immune response. Parasites will cause an increase in eosinophils in the complete blood count.

A nurse assessing an older adult for signs and symptoms of infection in the absence of a fever should assess for which of the following? Select all that apply.

Decreased mental status Fatigue Change in functional capacity Signs and symptoms of infection in an older adult in the absence of a fever include decreases in mental status and functional capacity, fatigue, weight loss, and weakness.

Pyrogens are substances that produce fever in the body. Substances such as bacterial products, bacterial toxins, or whole microorganisms enter the body and stimulate the host cells to produce certain mediators. What are these called?

Endogenous pyrogens Exogenous pyrogens, such as bacterial products, bacterial toxins, or whole microorganisms, induce host cells to produce fever-producing mediators called endogenous pyrogens. "Outer" and "set-point" pyrogens do not exist.

A deficiency in which of these would result in an inhibition of the inflammatory response?

Histamine Histamine is a key mediator in the inflammatory system, unlike helper T cells, B cells, or vitamin K.

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

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.

What is the most common cause of drug fever?

Hypersensitivity reaction to medication The most common cause of drug fever is a hypersensitivity reaction. Drug fever can also be caused by the antithyroid medication propylthiouracil (PTU), atropine and anticholinergic medications, antipsychotic agents, tricyclic antidepressants, cocaine, and amphetamines. The agitation, hyperthermia, and hyperactivity of serotonin syndrome occur with overdose of serotonin reuptake inhibitors.

A nurse instructing unlicensed assistive personnel (UAP) on temperature regulation includes as part of her teaching that core body and skin temperatures are sensed by which part of the brain?

Hypothalamus Core body and skin temperatures are sensed and integrated by the thermoregulatory regions in the hypothalamus.

In which client 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 seriously 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's ability to control skin blood flow and sweating.

A client has been diagnosed with osteomyelitis and admitted to the hospital. The client's fever persists throughout most of the day but returns to normal at least twice a day. Which pattern of fever is this client displaying?

Intermittent Intermittent fever patterns are very changeable, but they do return to normal at least once every 24 hours. A remitting fever pattern temperature does not return to normal and varies a few degrees in either direction. In a sustained fever pattern, the temperature remains above normal with minimal variations. A relapsing fever is one in which there is one or more episodes of fever, each as long as several days, with 1 or more days of normal temperature between episodes.

The nurse is evaluating the bloodwork results of a client with an infected leg ulcer. The white blood cell count is 18,000 cells/uL. The nurse interprets this as:

Leukocytosis A white blood cell count of 18,000 cells/uL is indicative of an elevated white blood cell count or leukocytosis (normal range is 4000-10,000 cells/uL). This would be an expected finding in a client with an infected leg ulcer. An increase in lymphocytes is lymphocytosis and neutropenia is a decrease in neutrophils. Lymphadenitis is an inflammation of the lymph nodes.

A client 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 client's physician has ordered a complete blood count and white cell differential. Which blood component 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.

A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?

Notify the physician The nurse should contact the physician, as the increase in the client's temperature is outside of the normal range and/or the normal diurnal variation in temperature.

A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?

Notify the physicianThe nurse should contact the physician, as the increase in the client's temperature is outside of the normal range and/or the normal diurnal variation in temperature.

Place the four successive stages of fever in correct order.

Prodromal Chill Flush Defervescence The physiologic behaviors that occur during the development of fever can be divided into four successive stages: a prodrome; a chill, during which the temperature rises; a flush; and a defervescence.

Diagnosing the primary cause is one of several methods used to treat fever. What are some other methods? Select all that apply.

Protection of vulnerable body organs and systems Modification of external environment to increase heat transfer from the internal to the external environment The methods of fever treatment focus on modifications of the external environment intended to increase heat transfer from the internal to the external environment, support of the hypermetabolic state that accompanies fever, protection of vulnerable body organs and systems, and treatment of the infection or condition causing the fever.

While a nurse is taking a client's history, the client states that he had a fever 2 days ago that went away for a day and then returned. The nurse documents this as being which type of fever?

Relapsing In a relapsing or recurrent fever, the client experiences one or more episodes of fever with one or more days of normal temperatures between episodes; therefore, the nurse would document this as a relapsing fever.

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 systemic inflammatory response syndrome. Systemic inflammatory response syndrome results in generalized vasodilation, increased vascular permeability, intravascular fluid loss, myocardial depression, and fatal circulatory shock.

A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later?

T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg During the chill phase of fever, the client feels cold and may experience pale skin with goosebumps, but the temperature is rising. When the body reaches the new set point, shivering will stop, and flushing will begin.

A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for:

Temperature Common clinical manifestations of fever include anorexia, myalgia, arthralgia, headaches, and fatigue; thus, the nurse should assess the client's temperature.

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 is experiencing pain The ankle appears to be swollen The client's ankle is visibly red The ankle is warmer than the unaffected ankle The cardinal signs of inflammation are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). Bleeding is not among the cardinal signs.

A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the client's temperature on admission and finds that it is 96.6°F (35.9°C). Which statement describes how the nurse should interpret the finding?

The client may 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.

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

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.

Which client is most likely to have impairments to the wound healing process? A client with:

poorly controlled blood sugars with small blood vessel disease. Diabetes mellitus is strongly associated with impaired wound healing. The other noted pathologies are less causative of deficiencies in the healing process.

A client has a mild headache and fatigue. He also states he has some aches and pains. Which stage of fever does the nurse determine the client is experiencing?

prodrome During the first or prodromal period there are nonspecific complaints such as mild headache and fatigue, general malaise, and fleeting aches and pains.

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. Leukocytosis, or the increase in white blood cells, is a frequent sign of an inflammatory response, especially those caused by bacterial infection. Leukocytosis occurs due to an increase in circulating neutrophils and eosinophils. Leukocytosis does not occur because of increased cell production, and blood supply is typically increased as part of the inflammatory process.

A client is said to be in the chill stage of the fever process when the nurse:

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.

A 33-year-old client is brought into the emergency room with a core temperature of 39°C (102.2°F). The client is red in the face, chest, and back due to significant cutaneous vasodilation. The client is likely in which stage of fever?

third The first stage of a fever is marked by headache and body aches, the second stage is marked by the chills, and the third stage is the flush state. The fourth stage is defervescence.