Chapter 3: Inflammation, the Inflammatory Response, and Fever Prep U
Which response by the nurse answers a client's question regarding the most common objective sign of systemic inflammation during the acute-phase response? Diarrhea Palpable lymph nodes Edema Fever
Fever
Which response by the nurse answers a client's question regarding the most common objective sign of systemic inflammation during the acute-phase response? Palpable lymph nodes Edema Diarrhea Fever
Fever
Which process would most likely be considered an anomaly during the cellular phase of inflammation? Vasoconstriction Platelet aggregation Macrophage activity Migration of phagocytic white cells
Vasoconstriction
A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as a/an: decrease in blood supply to the affected area. increase in cell production. increase in circulating neutrophils. decrease in eosinophils at the tissue injury site.
increase in circulating neutrophils.
A nurse's hand-off reports states that the client has pyrexia. The nurse plans care for the client who has: Wound Rash Incontinence Fever
Fever
A deficiency in which of these would result in an inhibition of the inflammatory response? B cells Helper T cells Histamine Vitamin K
Histamine
A health educator is teaching a group of colleagues about the physiology of thermoregulation. Which statement is most accurate? "PGE2 induces Kupffer cells to initiate a fever response via hepatic sinusoids." "Endogenous pyrogens induce host cells to produce exogenous pyrogens." "Arachidonic acid induces cytokines to act on the temperature regulation center." "Prostaglandin E2 (PGE2) exerts a direct fever-producing effect on the hypothalamus."
"Prostaglandin E2 (PGE2) exerts a direct fever-producing effect on the hypothalamus."
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? "Phagocytosis is the dynamic and energy-directed process where cells migrate, directed by chemoattractants." "The process of chemotaxis is the process where cells wander through the tissue guided by secreted chemoattractants." "The process of margination ensures that cells will follow the cytokine gradient." "Tissues have an abundance of inflammatory cells that are constantly migrating and just waiting for tissue injury."
"The process of chemotaxis is the process where cells wander through the tissue guided by secreted chemoattractants."
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. A 22 year old male with damage to his cerebellum secondary to a motorcycle accident. A 45 year old female with a T8 fracture secondary to a diving accident. A 68 year old male with end stage neurosyphilis.
A 66 year old male with damage to his thalamus secondary to a cerebral vascular accident.
A client with right lower quadrant abdominal pain is suspected to have acute appendicitis. When assessing the laboratory studies, what results would the nurse know indicate this client has an acute infection? An increase in T lymphocytes A decrease in eosinophils An increase in bands A decrease in platelet count
An increase in bands
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 is sometimes incapable of vasodilation. An older adult's hypothalamus has diminished thermoregulatory ability. An older adult is often insensitive to exogenous pyrogens. Infections manifest by cognitive changes in older adults.
An older adult's hypothalamus has diminished thermoregulatory ability.
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction? Lower the room temeprature Remove the client's blankets Give client a warm bath Apply cooling blanket
Apply cooling blanket
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? Placing the client in contact isolation immediately Requesting a repeat blood draw to verify the findings Notifying the physician of the abnormal lab result Continuing to monitor the client's laboratory results; this is an expected finding in an acute infection.
Continuing to monitor the client's laboratory results; this is an expected finding in an acute infection.
The loss of heat from the body through the circulation of air currents is known as: Radiation Conduction Evaporation Convection
Convection
A nurse's hand-off report states that a client's temperature is 106.6°F (41.4°C). What may have caused the client's temperature to elevate past 105.8°F (41°C)? Select all that apply. Convulsions Hyperthermic state Urinary tract infection Systemic infection
Convulsions Hyperthermic state
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. Change in fuctional capacity Decreased mental status Depression Fatigue Weight gain
Decreased mental status Change in fuctional capacity Fatigue
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 Outer pyrogens Exogenous pyrogens Set-point pyrogens
Endogenous pyrogens
A nurse who is providing a staff development in-service determines that the participants understand the information when they state that which bodily function aids heat conservation by reducing surface area for heat loss? Erection of pilomotor muscles Sweating Chattering Shivering
Erection of pilomotor muscles
A nurse who is providing a staff development in-service determines that the participants understand the information when they state that which bodily function aids heat conservation by reducing surface area for heat loss? Sweating Chattering Erection of pilomotor muscles Shivering
Erection of pilomotor muscles
Why is the risk of scarring and deformity greater in chronic inflammation than it is in acute inflammation? Chronic inflammation is often the result of allergic reactions. Chronic inflammation is the persistent destruction of healthy tissue. Typically, agents that evoke chronic inflammation are infections or irritants that penetrate deeply and spread rapidly. Fibroblasts instead of exudates proliferate in chronic inflammation.
Fibroblasts instead of exudates proliferate in chronic inflammation
A client is being treated for a pressure ulcer and the care team has observed that the wound is healing. Which activity will take place during the proliferative phase? Blood clots form at the wound site to prevent bleeding Fibroblasts secrete the cells necessary for wound healing White blood cells migrate the site of the client's wound Scar tissue is synthesized and becomes visible at the wound site
Fibroblasts secrete the cells necessary for wound healing
A client is being treated for a pressure ulcer and the care team has observed that the wound is healing. Which activity will take place during the proliferative phase? Blood clots form at the wound site to prevent bleeding Scar tissue is synthesized and becomes visible at the wound site Fibroblasts secrete the cells necessary for wound healing White blood cells migrate the site of the client's wound
Fibroblasts secrete the cells necessary for wound healing
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 Malnourished, hypomagnesemic, and hypocalcemic Cachexic and Asian Receiving intravenous normal saline with 20 mEq KCl
HIV positive and homeless
During the acute inflammatory response, there is a period called the transient phase where there is increased vascular permeability. What is considered the principal mediator of the immediate transient phase? Histamine Fibroblasts Cytokines Arachidonic acid
Histamine
What is the most common cause of drug fever? Hypersensitivity reaction to medication Serotonin syndrome Increased heat production from PTU Impaired peripheral heat dissipation by atropine
Hypersensitivity reaction to medication
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? Erratic Relapsing Remittent Intermittent
Intermittent
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? Erratic Remittent Relapsing Intermittent
Intermittent
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: Lymphadenitis Neutropenia Leukocytosis Lymphocytosis
Leukocytosis
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? Systemic Neurogenic Exogenous Intrinsic
Neurogenic
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? Basophils Platelets Eosinophils Neutrophils
Neutrophils
The route considered the most accurate to measure a core body temperature is: Rectal Thermosensoral (bladder) Esophageal Thermodilutional (pulmonary artery)
Rectal
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 physican. Offer the client a cold drink. Increase intravenous fluid rate. Document the temperature.
Notify the physican.
A nurse reading a client's history and physical notes that the client has had a remitting fever. The nurse interprets this to mean that the client's temperature has done what? Has had two fever episodes in 1 week Remained elevated with minimal variation Remained elevated but varied a few degrees Returned to normal within 24 hours
Remained elevated but varied a few degrees
Which client manifestation indicates signs of drug fever? Temperature reaches 41°C (105.8°F) after a sauna, pulse 76 beats/minute, skin hot and dry Temperature reaches 38°C (100.4°F) for 3 days, pulse 106 beats/minute, purulent drainage Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis Temperature reaches 39°C (102.2°F) following aerobic activity, pulse 125 beats/minute, sweating
Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis
A client is said to be in the chill stage of the fever process when the nurse: administers an antipyretic medication. observes piloerection on the skin. determines the client will benefit from a cool sponge bath. observes the client is sweating.
observes piloerection on the skin.
Which client is most likely to have impairments to the wound healing process? A client with: congenital heart defects and anemia. poorly controlled blood sugars with small blood vessel disease. a diagnosis of multiple sclerosis and consequent impaired mobility. chronic obstructive pulmonary disease.
poorly controlled blood sugars with small blood vessel disease.
A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for: Respirations Urinary output Temperature Hypothermia
Temperature
A nurse is assisting a client, who has a fever, order lunch. What would be the most appropriate food choice? Banana Toast Sandwich Omelette
Toast p. 67
Which clients are showing manifestations of infection? Select all that apply. A 5-year-old, temperature 36.8°C (98.2°F), talkative, actively engaged in playing A 75-year-old, temperature 37.3°C (99.2°F), declining mental status, weakness and fatigue A 50-year-old, temperature 36.2°C (97.3°F), heart rate 65 beats/min, muscle aches 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
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
Which symptom indicates the next stage of a fever after a prodrome? A flush A chill Defervescence Predrome
A chill
A client has been diagnosed with a fever of unknown cause. The nurse recognizes this as: A fever that only occurs in adults A fever that has responded well to several medications A fever of new onset A prolonged fever that does not have an identified source
A prolonged fever that does not have an identified source
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 mild parasitic infection A severe bacterial infection A mild viral infection A severe fungal infection
A severe bacterial infection
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 A mild viral infection A mild parasitic infection A localized fungal infection
A severe bacterial infection
A client is suspected to have developed chronic inflammation. Select the potential causes of the chronic condition. Select all that apply: Talc Penetrating trauma Asbestos Tubercle bacillus Suture Silica
Asbestos Silica Suture Talc Tubercle bacillus
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? Poor tissue oxygenation Avid feeding Cyanosis Hypoventilation
Avid feeding
The nurse is assessing a client with an elevated temperature. Which additional assessment findings provide the most useful information for the nurse? Client's blood culture was negative. Client's breathing is elevated. Client's skin is red. Client's heart rate is more rapid than anticipated.
Client's heart rate is more rapid than anticipated
The nurse is assessing a client with an elevated temperature. Which additional assessment findings provide the most useful information for the nurse? Client's skin is red. Client's breathing is elevated. Client's blood culture was negative. Client's heart rate is more rapid than anticipated.
Client's heart rate is more rapid than anticipated.
Which risk factor presents the greatest risk for injury in an older adult who is experiencing a dysfunction in temperature regulator function? Acute renal failure Misdiagnosis of pathology Acute dementia Delayed initiation of appropriate treatment
Delayed initiation of appropriate treatment
A client's body temperature has been documented as follows: 12 noon: 37°C (98.6°F); 6 pm: 37.5°C (99.5°F); 3 am: 36°C (96.8°F). Which action should the nurse take? Contact the physician. Retake the temperature. Document the temperature. Offer client a warm blanket.
Document the temperature.
A client's body temperature has been documented as follows: 12 noon: 37°C (98.6°F); 6 pm: 37.5°C (99.5°F); 3 am: 36°C (96.8°F). Which action should the nurse take? Document the temperature. Offer client a warm blanket. Retake the temperature. Contact the physician.
Document the temperature.
The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess? Pallor Tissue necrosis Hypothermia Edema
Edema
The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess? Tissue necrosis Hypothermia Edema Pallor
Edema
Which diagnostic lab test is used to diagnose the presence of inflammation? Bone marrow aspirate analysis Erythrocyte sedimentation rate Bone marrow biopsy Mean corpuscular volume
Erythrocyte sedimentation rate
Which diagnostic lab test is used to diagnose the presence of inflammation? Bone marrow biopsy Bone marrow aspirate analysis Erythrocyte sedimentation rate Mean corpuscular volume
Erythrocyte sedimentation rate
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 Exudate that resulted from leakage of red cells Exudate that is watery fluid, low in protein Exudate containing large amounts of fibrinogen
Exudate containing white blood cells, protein, and tissue debris
Which assessment finding correlates to the prodromal stage of a fever? Shivering Diaphoresis Reddened skin Fatigue
Fatigue
Which assessment finding correlates to the prodromal stage of a fever? Diaphoresis Shivering Fatigue Reddened skin
Fatigue During the first or prodromal period, there are nonspecific complaints, such as mild headache and fatigue, general malaise, and fleeting aches and pains.
A nurse's hand-off reports states that the client has pyrexia. The nurse plans care for the client who has: Incontinence Rash Fever Wound
Fever
Inflammation can be either local or systemic. What are the most prominent systemic manifestations of inflammation? Widening pulse pressure, thrombocytopenia, and the latent phase response Fever, leukocytosis or leukopenia, and the acute phase response Fever, leukocytosis or leukopenia, and the transition phase response Widening pulse pressure, thrombocytopenia, and the recovery phase response
Fever, leukocytosis or leukopenia, and the acute phase response
The nurse is caring for a client whose temperature is increasing. Which other vital sign/body response will the nurse monitor for an increase? Red blood cell count Blood pressure Heart rate Respiratory rate
Heart rate
Neurogenic fevers begin in the central nervous system. By what characteristics are neurogenic fevers known? Variable temperatures that are associated with sweating High temperatures that respond quickly to antipyretic therapy Temperatures that go up and down for no apparent reason High temperatures that are not associated with sweating
High temperatures that are not associated with sweating
A client with environmental allergies is experiencing respiratory inflammation. Which mediator causes vasodilation during the vascular stage of the inflammatory response? Adhesion molecules Histamine Leukotrienes Memory T cells
Histamine
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? Cerebellum Medulla Cerebral cortex Hypothalmus
Hypothalmus
Which aspect of a client's site of inflammation would help the care provider rule out chronic inflammation? High levels of macrophages Infiltration of lymphocytes Increased neutrophils Proliferation of fibroblasts
Increased neutrophils
Which aspect of a client's site of inflammation would help the care provider rule out chronic inflammation? High levels of macrophages Infiltration of lymphocytes Proliferation of fibroblasts Increased neutrophils
Increased neutrophils
In which client with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation? Injury at T9 Injury at L4 Injury at L1 Injury at T2
Injury at T2
The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation? Sepsis Fever Loss of function Altered level of consciousness
Loss of function
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? T cells B cells Macrophages Neutrophils
Macrophages
Most febrile illnesses are due to common infections and are relatively easy to diagnose. In certain instances, however, it is difficult to establish the cause of a fever. In these instances, the elevation in temperature is referred to as a fever of unknown origin (FUO). What is a common cause of FUO? Femoral artery emboli Pulmonary emboli Disseminated intravascular coagulation Malignancies
Malignancies
Place the four successive stages of fever in correct order. Prodromal Flush Chill Defervescence
Prodromal Chill Flush Defervescence
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 Chill Defervescence Flush
Prodrome
The nurse needs to assess a 1-year-old child for fever. Which approach will produce the mostaccurate reading? Oral Forehead Rectal Axillary
Rectal
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? Continuous Remittent Intermittent Relapsing
Relapsing
A client reports having three episodes of fever that have lasted several days, with periods of normal temperature in between the episodes for 2 or more days. Which type of fever is the client experiencing? Relapsing fever Intermittent fever Continuous fever Remittent fever
Relapsing fever
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's absent febrile response indicates absence of an infection. The client may be exhibiting a blunted or absent febrile response. The client's temperature is normal so the client does not have an infection. The client is exhibiting a normal febrile response to a urinary tract infection.
The client may be exhibiting a blunted or absent febrile response. p. 68
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 is warmer than the unaffected ankle The ankle is bleeding The client's ankle is visibly red The ankle appears to be swollen
The client's ankle is visibly red The ankle appears to be swollen The ankle is warmer than the unaffected ankle The client is experiencing pain
The medical team is assessing a newly admitted client who is hypothermic following a night spent lost on a ski slope. The health care professionals would recognize that which phenomenon most likely contributed to minimizing the client's heat loss in a cold environment? Increased blood flow to the outer shell prevented superficial freezing and loss of heat. The high heat conductivity of subcutaneous tissue protected against core heat loss. Shell temperature dropped, minimizing the temperature variance between core and environment. The tissue thickness of the outer shell increased and preserved heat.
The tissue thickness of the outer shell increased and preserved heat.
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? First Second Fourth Third
Third (Flush)
The nurse is caring for a client with a stab wound. The nurse recognizes that deficiency of which of these elements of the blood will interfere with hemostasis at the site of injury? Thrombocytes Neutrophils Lymphocytes Erythrocytes
Thrombocytes
Purulent exudate contains which substances? Select all that apply. Tissue debris White blood cell by-products Fibrinogen Fibrin Red blood cells
Tissue debris White blood cell by-products
Which process would most likely be considered an anomaly during the cellular phase of inflammation? Platelet aggregation Vasoconstriction Macrophage activity Migration of phagocytic white cells
Vasoconstriction
A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as a/an: increase in cell production. decrease in eosinophils at the tissue injury site. increase in circulating neutrophils. decrease in blood supply to the affected area.
increase in circulating neutrophils.
A client who has developed a fever is now reporting a headache. The nurse would recognize this manifestation as a result from the: vasodilatation of cerebral vessels. vasoconstriction of cerebral vessels. vasodilatation of coronary vessels. vasoconstriction of coronary vessels.
vasodilatation of cerebral vessels.
A client who has developed a fever is now reporting a headache. The nurse would recognize this manifestation as a result from the: vasodilatation of coronary vessels. vasoconstriction of cerebral vessels. vasoconstriction of coronary vessels. vasodilatation of cerebral vessels.
vasodilatation of cerebral vessels.