Chapter 3 - Inflammation, the Inflammatory Response, and Fever

A client asks the nurse what is the most common objective symptom of systemic inflammation during the acute-phase response. The best response would be:

Fever Explanation: 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.

A nurse's hand-off reports states that the patient has pyrexia. The nurse plans care for the patient with which of the following events?

Fever Explanation: When a patient is documented to have pyrexia, the nurse should plan care for a patient with a fever.

A client who is scheduled for orthopedic surgery has expressed concern about the risk of malignant hyperthermia. The nurse should reassure the client that the anesthesiologist will:

carefully assess the client's genetic risk of the problem. Explanation: Family history is a significant factor when appraising a client's risk of malignant hyperthermia. Dantrolene is only administered if active treatment is needed. Antipyretics are ineffective. Intubation is necessary during surgery but does not prevent malignant hyperthermia.

Which of the following can the nurse tell a patient about antipyretic drugs during fever?

"Antipyretics help to protect the body." Correct 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 of the following statements is most accurate?

"Prostaglandin E2 (PGE2) exerts a direct fever-producing effect on the hypothalamus." Explanation: PGE2 is the protein that exerts control on the hypothalamus and induces fever. Exogenous pyrogens induce host cells to produce endogenous pyrogens, and Kuppfer cells produce PGE2. Cytokines do not act directly in the hypothalamus.

Which symptom indicates the next stage of a fever after a prodrome?

A chill Explanation: 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.

A client presents with an oral temperature of 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.

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

Chill Explanation: During the second phase or chill phase of fever development, the patient'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 patient is in the second or chill phase of fever development.

The loss of heat from the body through the circulation of air currents is known as which of the following?

Convection Explanation: 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 client with environmental allergies is experiencing respiratory inflammation. Which mediator causes vasodilation during the vascular stage of the inflammatory response?

Histamine Explanation: Histamine is a key mediator in the inflammatory system and one that induces vasodilation during the vascular stage. Adhesion molecules, memory T cells, and leukotrienes do not participate in the process of vasodilation during the vascular stage.

Which of the following patients is most likely to have impairments to the wound healing process? A patient 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.

A nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for:

Rubor, swelling, and pain Explanation: 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.

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 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.

• Fatigue • Decreased mental status • Change in fuctional capacity Explanation: 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.

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.

4000 to 10,000 cells/μL Explanation: 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 neurologic unit of a hospital. With which client is the nurse justified in predicting a problem with thermoregulation?

66-year-old man with damage to his hypothalamus secondary to a cerebral vascular accident. Explanation: The hypothalamus 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.

A 24-year-old woman presents with fever and painful, swollen cervical lymph nodes. Her blood work indicates neutrophilia with a shift to the left. She most likely has:

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. Explanation: 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 of the following is an appropriate action by a nurse to take in attempting to decrease a patient's temperature through conduction?

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

A client taking the typical antipsychotic agent haloperidol (Haldol) experiences neuroleptic malignant syndrome. What nursing intervention is highest priority after stopping the medication?

Cooling blanket Explanation: Neuroleptic malignant syndrome (NMS) is a life-threatening condition most often triggered by typical antipsychotic agents such as haloperidol (Haldol) and chlorpromazine (Thorazine). The condition usually has sudden onset of hyperthermia, muscle rigidity, change in mental status, and autonomic dysfunction seen in labile blood pressure, dyspnea, and tachycardia. The priority interventions are to stop the medication and reduce the temperature using a cooling blanket or ice packs in the axillae and groin. Subsequent interventions of IV fluids and ventilator support are directed at controlling symptoms and supporting body systems. Dopamine agonists such as bromocriptine have been used to reduce the effect of the triggering neuroleptic agent. Benzodiazepines such as diazepam can be used to reduce anxiety.

A nurse who is providing a staff development in-service determines that the participants understand the information when they state that which of the following aids heat conservation by reducing surface area for heat loss?

Erection of pilomotor muscles Explanation: The nurse determines that the participants understand the information when they identify that erection of pilomotor muscles aids heat conservation by reducing surface area for heat loss.

A client has an increase in core body temperature. What assessment findings does the nurse expect?

Flushed skin Explanation: The client with an increase in their core temperature will be accompanied by flushed, warm skin as the body tries to lower the temperature. The other assessments do not correlate with increased core temperature.

A nurse is providing care for a 44-year-old male client who is admitted with a diagnosis of fever of unknown origin (FUO). Which characteristic of the client's history is most likely to have a bearing on his current diagnosis?

HIV positive and homeless Explanation: FUO is associated with HIV. The other aspects of the client's circumstances are not noted to correlate with FUO.

What is the most common cause of drug fever?

Hypersensitivity reaction to medication Explanation: 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 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 Explanation: 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.

A patient has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for the patient with which of the following types 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 patient with a neurogenic fever.

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 Explanation: 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.

The nurse is attempting to obtain the most accurate core body temperature of a patient. Which of the following methods should the nurse use?

Rectal Explanation: The rectal temperature is considered the most accurate parameter for measuring core body temperature compared to oral, axillary, and ear based.

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 Explanation: 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.

A client has a watery fluid leaking from a site of inflammation. The nurse would document this type of exudate as:

Serous Explanation: Serous exudate is a watery fluid low in protein content that results from plasma entering the inflammatory site. Hemorrhagic exudate is red or blood tinged related to damage to blood vessels. Suppurative exudate is composed of degraded white blood cells and tissue debris, leaving the fluid pus-like. Fibrinous exudate is thick and sticky meshwork fluid.

A client has developed systemic inflammatory response syndrome. The nurse is aware that this results from:

Severe bacterial infections (sepsis) Explanation: 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.

A client with pneumonia is admitted with these vital signs: temperature 99.7ºF, pulse 80 beats/min, respirations 18/minute, and BP 120/80 mmHg. 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, P 90/min, R 20/min, BP 126/80 mmHg Explanation: 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 patient is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for which of the following?

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

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 patient may be exhibiting a blunted or absent febrile response. Explanation: 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 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 of the following patients are at increased risk for hyperthermia? Select all that apply.

• Quadriplegic attending an outdoor summer event • Patient with heart disease in an nonairconditioned vehicle • Patient with schizophrenia taking haloperidol Thermoregulation that is controlled by the hypothalamus is impaired in patients 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.

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

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. Explanation: 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.

An older adult's dysfunctional temperature regulator function places the client at greatest risk for:

Delayed initiation of appropriate treatment Explanation: 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.

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

Edema Explanation: Cardinal signs of inflammation include rubor (redness), tumor (swelling or edema), calor (heat), dolor (pain) and functiolaesa (loss of function). Tissue necrosis occurs with chronic inflammation.

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 Explanation: 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

The nurse is caring for a client whose temperature is increasing. The nurse is aware that the client will also experience an increase in:

Heart rate Explanation: Critical to the analysis of a fever pattern is the relation of heart rate to the level of temperature elevation. Normally, a 1°-C rise in temperature produces a 15-bpm (beats/minute) increase in heart rate (1°F, 10 bpm). The remaining options are not as closely related as is heart rate.

A nurse instructing unlicensed personnel on temperature regulation includes that core body and skin temperatures are sensed by which of the following parts of the brain?

Hypothalmus Explanation: Core body and skin temperatures are sensed and integrated by the thermoregulatory regions in the hypothalmus.

A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as an:

Increase in circulating neutrophils Explanation: 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 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 Explanation: 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.

Place the four successive stages of fever in correct order.

Prodromal Chill Flush Defervescence Explanation: 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.

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.

The route considered the most accurate to measure a core body temperature is which of the following?

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

An older adult client with a history of chronic obstructive pulmonary disease (COPD) develops a fever of 38.3ºC (101ºF). What is the primary reason for the nurse to implement temperature lowering measures?

Reduce oxygen demand Explanation: Fever can be beneficial under certain circumstances. Relatively small increases in fever can stimulate immune response by T lymphocyte proliferation. The growth of many microbes is inhibited at temperatures in the fever range. Fever can cause discomfort such as headache and body aches. Fever above 42.2ºC (108ºF) can cause cell damage and life-threatening acidosis, hypoxia, and hyperkalemia. Older adults with cardiac or pulmonary conditions who develop fever are at risk of hypoxia because each degree of temperature elevation in Celsius raises the basal metabolic rate by about 7%. In a client with an average body temperature of about 37ºC (98.6ºF), the rise to 38.3ºC would increase the metabolic demand by more than 7%. A client with longstanding COPD would have difficulty maintaining adequate oxygen saturation.

When a patient reports having three episodes of fever that has lasted several days, with periods of normal temperature in between the episodes for 2 or more days. Which type of fever is the patient experiencing?

Relapsing fever Explanation: A recurrent or relapsing fever is one in which there is one or more episodes of fever that last several days, with one or more days of normal temperature between episodes. With remittent and continuous fever the patient does not experience a return to a normal temperature level. Intermittent fever returns to normal at least once every 24 hours, but this is not consistent with the patient's description above.

Which temperature readings indicate to the nurse that the clients have fever? Select all that apply.

• 35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) • 19-year-old with oral reading of 38.4ºC (101.1ºF) • 3-day-old with rectal reading of 38ºC (100.4ºF) Explanation: A core body temperature reading can be obtained from the esophagus, pulmonary artery catheter, a urinary catheter probe, or the rectum. For rapidly fluctuating temperatures, the pulmonary artery is most accurate. An oral temperature is generally lower than core by about 0.5ºC (1ºF). Axillary temperatures are approximately 0.5ºC (1ºF) lower than oral. A fever is temperature elevation above the body's normal set point which is usually between 36ºC (97ºF) and 37.5ºC (99.5ºF).

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 25-year-old, temperature 40°C (104°F), sweating, shivering, states generalized pain • A 75-year-old, temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue 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.