Patho - Chapter 3
Which statement will the nurse include when teaching a client with Crohn disease about dietary restrictions during an exacerbation? "Eat foods high in fat and calories." "Avoid dairy foods and eggs." "Eat foods low in fat and fiber." "Avoid seeds and whole grains."
"Eat foods low in fat and fiber." Explanation: Dietary modifications and restrictions are required for the client with Crohn disease in order to decrease exacerbations and manifestations of the disease. Irritating foods, such as spicy foods, should be avoided. Clients should be taught to eat foods high in calories and protein during remission and low in fat and fiber during exacerbation of the disease. The additional answer choices do not reflect the dietary recommendations for the client with Crohn disease.
A nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for: Rubor, swelling, and pain Cyanosis, heat, and swelling Pain, pulselessness, and edema Paresthesias, redness, and coolness
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.
9. Which of the following is the most common cause of acute gastritis? a. Poor gastric perfusion b. Too much stomach acid c. Ingestion of aspirin, alcohol, or other chemicals d. H. pylori infection
D. H. Pylori infection
The nurse is caring for a client who reports chronic joint pain. Which statement(s) by the client indicates that the client most likely has rheumatoid arthritis? (Select all that apply.) "I have been so tired lately." "I have a low-grade fever on and off." "I don't have much of an appetite." "Only one of my hands seem to swell and hurt." "My joints feel warm to the touch."
"I have been so tired lately." "I have a low-grade fever on and off." "My joints feel warm to the touch." "I don't have much of an appetite." Explanation: Manifestations of rheumatoid arthritis (RA) include fatigue, low-grade fever, warmth of joints from inflammation, and anorexia. RA causes symmetrical deformity, affecting both extremities in the same manner.
A person has fallen and injured a lower extremity. The leg appears reddened and edematous. What anatomic event(s) has occurred to get such a response at the site of the injury? Select all that apply. increase in formation of mast cells vasodilation of the vessels sticky yellow exudate formation at the injury site increased permeability in the lining of the blood vessel tightening of the endothelial cells
vasodilation of the vessels increased permeability in the lining of the blood vessel Explanation: Anatomically, the structure of the blood vessels must change to accommodate this increase in emergency vehicle traffic. The blood vessels dilate or widen, to accommodate increased blood flow to the site of injury. Also, the lining of the blood vessel becomes more permeable or loosens to allow cells to easily move from the vessel into the injured tissue. Loosening of the blood vessel must occur with the basement membrane of the blood vessel and adjacent endothelial cells. Endothelial cells form a tight junction within the inner lining of the heart, blood vessels, and lymphatic vessels. Endothelial cells are connected to the basement membrane, a noncellular sheet that separates the vessel from the tissues of the body. The vessel walls are needed to confine blood cells and plasma, but with injury, they must be loosened to allow for the movement of healing fluids and cells into damaged tissues. Exudate accumulates at the site of injury and has a high protein and leukocyte concentration. The placement of mast cells allows for a rapid response directly at the site of the injury. The mast cell is responsible for the production and immediate release of inflammatory mediators through degranulation, the process by which mast cells break apart and release inflammatory mediators in the form of extracellular granules.
11. A patient is taking an anti-inflammatory drug for rheumatoid arthritis. What is the most likely action for this drug? a. Blocks the chemical mediators of inflammation b. Enhances the body's immune system c. Increases blood flow to the tissues d. Decreases scar formation
A. Blocks the chemical mediators of inflammation
7. The hospitalized burn patient wants to know why you need to remove his dressings every day. It is painful and he wants to avoid uncovering his burn injury. You explain that removing the dressings promotes: a. Debridement b. Infection c. Skin function d. Drying the exudate
A. Debridement
3. A wound is 6 cm × 6 cm × 4 cm. A wound with these dimensions needs to heal through: a. Secondary intention b. Primary intention c. Tertiary intention d. Scar tissue formation
A. Secondary intention
When assessing the client with acute pancreatitis, which of these diagnostic tests—consistent with the disease— does the nurse anticipate will be altered? Glucose values Amylase and lipase Creatine kinase The transaminases
Amylase and lipase Explanation: Serum amylase and lipase are the laboratory markers most commonly used to establish a diagnosis of acute pancreatitis.
6. Depth of injury is important to determine with burns. You are in the sun too long without sunscreen and develop redness and blistering on your face, chest, and back. What depth of burn did you experience? a. Superficial partial-thickness burn b. Deep partial-thickness burn c. Full-thickness burn d. Dermal thickness burn
B. Deep partial thickness burn
1. You get a paper cut and experience pain at the site. This response is related to: a. Increased perfusion at the site b. Increased exudate and chemical mediators at the site c. Bacteria that have entered the wound d. Vasoconstriction at the site
B. Increased exudate and chemical mediators at the site
10. Why is Crohn disease more likely to cause intestinal obstruction than ulcerative colitis? a. Crohn disease is located in the small intestine. b. Crohn disease causes granulomas to form in the submucosal layer. c. Crohn disease causes abdominal pain and watery diarrhea. d. Crohn disease is exacerbated by certain foods, such as spicy foods.
Crohn disease causes granulomas to form in the submucosal layer
5. Which is not a local manifestation of acute inflammation? a. Edema b. Redness c. Loss of function d. Leukocytosis
D. Leukocytosis
8. What is the one definitive test to diagnose rheumatoid arthritis? a. A positive rheumatoid factor (RF) b. An elevated erythrocyte sedimentation rate (ESR) c. A positive antinuclear antibody (ANA) d. One test is not definitive
D. One test is not definitive
2. Inflammation is ultimately needed to: a. Increase inflammatory mediators at the site to vasoconstrict the area b. Increase platelets at the site for clotting c. Restore functional cells d. Prepare the site for healing
D. prepare the site for healing
14. Which of the following meals would you recommend to a patient with a wound to promote healing? a. Eggs and orange juice b. Spaghetti and garlic toast c. Steak and potatoes d. Tomato soup and grilled cheese
Eggs and orange juice
After a tornado, an adolescent was found dead near a "live" wire from a downed electrical pole. While trying to explain to the family what caused this death, which statement(s) by the nurse is appropriate? Select all that apply. Because the electrical wire was a higher temperature than normal, a thermal burn occurred inside the cells. Most electrical burns just cause a burn to the body part that touched the line, but not in this case. Electrical currents disrupt cardiac conduction and cause immediate death. Electrical injuries follow the path of least resistance, that is along tissues, fluids, and blood vessels. The electrical current can pass through organs and blood vessels.
Electrical injuries follow the path of least resistance, that is along tissues, fluids, and blood vessels. The electrical current can pass through organs and blood vessels. Electrical currents disrupt cardiac conduction and cause immediate death. Explanation: Burns can result from thermal injury, electrical injury, caustic chemical injury, radiation exposure, or inhalation of noxious fumes. Electrical injuries follow the path of least resistance in the body, that is along tissues, fluids, blood vessels, and nerves. Serious electrical trauma results from the electrical current passing through vital organs, nerves, and blood vessels. Electrical currents can disrupt cardiac conduction and cause immediate death. In thermal injuries, higher temperature and increased length of heat exposure increase the severity of the burn. Temperatures higher than 113°F (45°C) cause proteins to denature, and irreversible cellular damage occurs. The extent of damage from chemical injuries depends on the toxicity of the chemical, location of exposure (particularly in the eyes, respiratory tract, or gastrointestinal tract), and length of exposure.
12. Which of the following is the most common cause of acute pancreatitis? a. Cancer b. Autoimmunity c. Excess alcohol intake d. Cystic fibrosis
Excess alcohol intake
Which body response to an acute inflammation will the nurse assess if the client is experiencing a systemic response? Positive nitrogen balance Bradycardia and hypertension Fever and tachycardia Decreased C-reactive protein
Fever and tachycardia Explanation: The acute-phase system response includes fever, hypotension, and increased heart rate [tachycardia], anorexia, release of neutrophils into the circulation, and increased levels of corticosteroid hormones.
In clients with acute diarrhea, many require no treatment. However, the nurse knows the priority assessment in all clients with diarrhea is: Skin integrity Fluid and electrolyte status Stool specimen Dietary intake
Fluid and electrolyte status Explanation: Although most acute forms of diarrhea are self-limited and require no treatment, diarrhea can be particularly serious in infants and small children, persons with other illnesses, elderly persons, and even previously healthy persons if it continues for any length of time. Thus, the replacement of fluids and electrolytes is considered to be a primary therapeutic goal in the treatment of diarrhea.
4. A major difference between the acute and chronic inflammatory response is that in chronic inflammation: a. Inflammatory mediators are released b. Neutrophils are much more prominent c. Granulomas form around certain invaders d. Granulation tissue is present
Granulation tissue is present
A client fell off his motorcycle, receiving several large abrasion-related surface wounds. What physiologic phenomenon will the client first experience? Maturation Healing by secondary intention Healing by primary intention Remodelling
Healing by secondary intention Explanation: Due to the mechanism of injury, deep and wide wounds requiring healing by secondary intention will occur. Secondary intention results in the formation of larger amounts of scar tissue. A sutured surgical incision is an example of healing by primary intention. Remodelling or maturational phase is the third and final phase of healing.
13. Rheumatoid arthritis results in joint immobility as a result of: a. Synovial fluid loss b. Pannus formation c. Rheumatoid factor d. Joint deviation
Pannus Formation
The nurse is assessing the wound of a postoperative client. The client has a 6-inch abdominal wound that is well approximated and closed with surgical suture. The wound does not display any redness or drainage. The nurse would document the healing process as: Primary intention Progressive intention Secondary intention Tertiary intention
Primary intention Explanation: A sutured surgical incision is an example of healing by primary intention. Secondary intention is slower than healing by primary intention and results in the formation of larger amounts of scar tissue. Tertiary intention is a wound that is open and needs to be closed when granulation tissue forms. There is not a progressive intention.
Following hip replacement surgery, the client has had many weeks of physical therapy. Upon assessing the wound, it is still red and draining thick, green, odoriferous secretions. The client has limited range-of-motion and is constantly reporting pain. The physician explains that the hip device needs to be removed. Why is removal required? No amount of antibiotic therapy will be able to reach the area around the new joint and kill the infection. A fragment of bone may be rubbing at the insertion site of the joint and keeping it inflamed. The device is impeding the supply of nutrients and oxygen to reach the inflamed area. The body considers the hip replacement device a foreign body and an infection has developed around the joint.
The body considers the hip replacement device a foreign body and an infection has developed around the joint. Explanation: Wound infections are of special concern in persons with implantation of foreign bodies such as orthopedic devices (e.g., pins, stabilization devices), cardiac pacemakers, and shunt catheters. These infections are difficult to treat and may require removal of the device.
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): Pustule Ulceration Abscess Fungus
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
The nurse is assessing a client for acute inflammation of a wound. Which symptom does the nurse attribute to the acute inflammatory response? pallor tissue necrosis hypothermia edema
edema Explanation: Cardinal signs of inflammation include rubor (redness) rather than pallor, tumor (swelling or edema), calor (heat), dolor (pain) and functio laesa (loss of function). Tissue necrosis occurs with chronic inflammation.
While the nurse is performing a skin assessment on a dark-skinned client, the nurse notes that the client has a healed wound on the leg but that the wound has an excess of scar tissue. The nurse documents this as: epithelialization. keloid. remodeling. proud flesh.
keloid. Explanation: The nurse documents the existence of excess of scar tissue on a healed wound as a keloid. These are more common in black clients. Proud flesh is an excess of granulation tissue in a healing wound. Remodeling is the third phase of wound healing. Epithelialization is the migration, proliferation, and differentiation of epithelial cells on the wound edges and occurs during the proliferative phase of wound healing.
After many years of cigarette smoking, a client is admitted to have a "mass" removed from the lung. When explaining the surgery and recovery, the physician notes that the client is likely to have a good amount of fibrosis develop at the surgical area. After the physician leaves the room, the client asks the nurse what was meant by "fibrosis" in the lung. The nurse bases the response on the fact that tissue repair can: be slowed in an aging adult, and therefore may end up with part of the scar not being able to perform its normal function. result in replacement tissue in the form of connective (fibrous) tissue, which leads to scar formation or fibrosis of the lung. result with injured cells being replaced with cells of the same type. form an extracellular matrix (like a web), which is composed of connective tissue that ends up being scar tissue at the surgical site.
result in replacement tissue in the form of connective (fibrous) tissue, which leads to scar formation or fibrosis of the lung. Explanation: Tissue repair can take the form of replacement by connective (fibrous) tissue, which leads to scar formation or fibrosis in organs such as the liver or lung. Regeneration of tissue results with injured cells being replaced with cells of the same type. Although age does play a role in tissue healing, it is not the only factor that can result in scar formation.