Patho Exam 1 Ch 3

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?

"The process of chemotaxis is the process where cells wander through the tissue guided by secreted chemoattractants."

Place the four successive stages of fever in correct order. -Chill -Defervescence -Flush -Prodromal

1. Prodromal 2. Chill 3. Flush 4. Defervescence

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.

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 yo male with damage to his thalamus secondary to a cerebral vascular accident.

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

A chill.

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.

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.

An agricultural worker is picking fruit on a day when the air temperature is 106°F. Which of the following processes will most likely be occurring while he works?

Blood volume to his skin surface will be increasing to dissipate heat.

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.

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

Edema.

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

Erection of pilomotor muscles.

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.

The nurse is assessing a client who is in the prodromal stage of a fever. The nurse anticipates the client will exhibit:

Fatigue.

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.

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.

What is the most common cause of drug fever?

Hypersensitivity reaction to medication.

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.

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

Increase in circulating neutrophils.

In which of the following patients with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation?

Injury at T2.

A patient's temperature readings are as follows: 99.6°F at 4 pm; 102°F at 8 pm; and 97.9°F at 12 am. The nurse's hand-off should include which of the following?

Intermittent fever.

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.

The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation?

Loss of function.

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.

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.

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.

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.

An older adult client with a history of COPD develops a fever of 38.3°C. What is the primary reason for the nurse to implement temperature lowering measures?

Reduce oxygen demand.

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

Rubor, swelling, and pain.

Which of the following would be an appropriate action for a nurse to take in attempting to decrease a patient's temperature through radiation heat loss?

Set the room to a lower 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 degrees F. Which of the following describes how the nurse should interpret the finding?

The patient may have been exhibiting a blunted or absent febrile response.

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.

Select the most accurate and comfortable route for the nurse to assess the temperature of an elderly client:

Tympanic route.

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.