Prep U: Ch 3: Inflammation, the Inflammatory Response, and Fever

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.

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

rectal

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

"Antipyretics help to protect the body." explanation: 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 health educator is teaching a group of colleagues about the physiology of thermoregulation. Which statement is most accurate?

"Prostaglandin E2 (PGE2) exerts a direct fever-producing effect on the hypothalamus."

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

A 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis 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 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.

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

Apply cooling 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 Explanation: 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.

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

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

Convection

What is the most common cause of drug fever?

Hypersensitivity reaction to medication

Place the four successive stages of fever in correct order.

Prodromal Chill Flush Defervescence

The nurse notes that a clent's core body temperature is 43°C (109.4°F). What is the correct interpretation by the nurse?

The ability of the client's body to thermoregulate is impaired.

The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess?

edema

The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis?

sepsis

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 Explanation: 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.

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 Explanation: 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.

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 Change in fuctional capacity Fatigue

A client has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for which type of fever?

Neurogenic Explanation: Neurogenic fever has its origin in the central nervous system and is usually caused by damage to the hypothalamus from trauma, intercranial bleeding, or increased intercranial pressure. The nurse should plan care for a client with a neurogenic fever.

The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading?

Rectal Explanation: Measurement of core body temperature is important when evaluating fever. The rectal route is considered the most accurate. In adults and older children, the oral route is lower, but still accurate; however, in young children the oral route may be unreliable. Forehead thermometers can predict trends, but are not as accurate as other routes. The axillary route requires up to 10 minutes for the temperature to register appropriately.

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

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

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

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

The nurse is caring for a client with an elevated temperature. Which of the following other symptoms might the nurse expect the patient to be experiencing? Select all that apply.

Fatigue Weakness

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

Which clients are at increased risk for hyperthermia? Select all that apply.

Quadriplegic attending an outdoor summer event Client with heart disease in an nonairconditioned vehicle Client with schizophrenia taking haloperidol Explanation: Thermoregulation that is controlled by the hypothalamus is impaired in clients with spinal cord injuries higher than T6 because they are not able to receive signals to vasodilate or sweat below the level of injury. Circulation of blood to the body surface helps to cool the body. Individuals with heart disease have reduced capacity to dissipate heat. Medications that predispose clients to hyperthermia include diuretics, neuroleptics, and anticholinergics.

Which client manifestation indicates signs of drug fever?

Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis explanation: Clients with drug fever often show signs of hypersensitivity such as joint pain, itching, rashes, muscle pains, and gastrointestinal distress. The fever has a diurnal pattern with the highest point in the afternoon or early evening. The clients in the other options are exhibiting signs of infection, heat exhaustion, and heatstroke.

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 is warmer than the unaffected ankle The client is experiencing pain The ankle appears to be swollen