patho phys ch.3
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
The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation?
loss of function
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
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.
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
The nurse needs to assess a 1-year-old child for fever. Which approach will produce the most accurate reading?
rectal
The route considered the most accurate to measure a core body temperature is:
rectal
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
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:
severe bacterial infection
A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for:
temperature
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 (flush)
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
What can the nurse tell a client about antipyretic drugs during fever?
"Antipyretics help to protect the body."
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."
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."
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
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.
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.
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?
Apply cooling blanket
The nurse is assessing a client with an elevated temperature. Which additional assessment findings provide the most useful information for the nurse?
Client's heart rate is more rapid than anticipated.
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 functional capacity Fatigue
Inflammation can be either local or systemic. What are the most prominent systemic manifestations of inflammation?
Fever, leukocytosis or leukopenia, and the acute phase response
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?
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
An 8-year-old boy has fallen through the ice while skating on a frozen pond. By the time paramedics arrive, the boy has been removed from the water by his friends, but his core body temperature is 31.1°C (88.0°F). The responders would recognize that which physiologic process would have been active during the boy's accident?
Heat production through increased body metabolism
Which aspect of a client's site of inflammation would help the care provider rule out chronic inflammation?
Increased neutrophils
Why does subcutaneous fat affect the body's ability to insulate itself? Select all that apply.
It adds thickness to the body's outer shell Its poor ability to conduct body heat
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 physician.
Place the four successive stages of fever in correct order.
Prodromal Chill Flush Defervescence
A nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for:
Rubor, swelling, and pain
The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis?
Sepsis
In which client with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation?
T2
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 may be exhibiting a blunted or absent febrile response.
The nurse notes that a client's core body temperature is 43°C (109.4°F). What is the correct interpretation by the nurse?
ability of client's body to thermoregulate is impaired
The loss of heat from the body through the circulation of air currents is known as:
convection
The nurse is assessing a client for acute inflammation of a wound. For which symptom 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 that which bodily function aids heat conservation by reducing surface area for heat loss?
erection of pilomotor muscles
A deficiency in which of these would result in an inhibition of the inflammatory response?
histamine
What is the most common cause of drug fever?
hypersensitivity to medication
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?
hypothalmus
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
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
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.
A nurse notes that a client with a fever has begun to shiver. The nurse should assess for which event?
Increased temperature
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 appears to be swollen The ankle is warmer than the unaffected ankle The client is experiencing pain
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
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?
neutrophils
A client is said to be in the chill stage of the fever process when the nurse:
observes piloerection on skin
