PrepU Chapter 3: Inflammation, the Inflammatory Response, and Fever
A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as a/an: decrease in eosinophils at the tissue injury site. decrease in blood supply to the affected area. increase in circulating neutrophils. increase in cell production.
increase in circulating neutrophils.
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. 1500 to 20,000 cells/μL 1000 to 3000 cells/μL 14,000 to 20,000 cells/μL 4000 to 10,000 cells/μL
4000 to 10,000 cells/μL
Which symptom indicates the next stage of a fever after a prodrome? Defervescence A chill A flush Predrome
A chill
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 Cyanosis Poor tissue oxygenation Hypoventilation
Avid feeding
A client with a rising temperature is pale and has begun to shiver. The nurse reports that the client is in which phase of fever development? Flush Chill Prodrome Defervescence
Chill
The loss of heat from the body through the circulation of air currents is known as: Evaporation Radiation Conduction Convection
Convection
Why is the risk of scarring and deformity greater in chronic inflammation than it is in acute inflammation? Fibroblasts instead of exudates proliferate in chronic inflammation. Typically, agents that evoke chronic inflammation are infections or irritants that penetrate deeply and spread rapidly. Chronic inflammation is often the result of allergic reactions. Chronic inflammation is the persistent destruction of healthy tissue.
Fibroblasts instead of exudates proliferate in chronic inflammation.
In which client with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation? Injury at L1 Injury at T9 Injury at L4 Injury at T2
Injury at T2
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? Intrinsic Neurogenic Systemic Exogenous
Neurogenic
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 physician.
Place the four successive stages of fever in correct order. Prodromal Defervescence Flush Chill
Prodromal Chill Flush Defervescence
The nurse needs to assess a 1-year-old child for fever. Which approach will produce the mostaccurate reading? Oral Rectal Forehead Axillary
Rectal
The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis? Sepsis Anaphylactic shock Respiratory arrest Acute renal failure
Sepsis
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 Fourth Second First
Third
Which temperature readings indicate to the nurse that the clients have fever? Select all that apply. 77-year-old with tympanic reading of 36.3ºC (97.3ºF) 35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) 19-year-old with oral reading of 38.4ºC (101.1ºF) 2-year-old with axillary reading of 35.8ºC (96.4ºF) 3-day-old with rectal reading of 38ºC (100.4ºF)
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)
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 50-year-old, temperature 36.2°C (97.3°F), heart rate 65 beats/min, muscle aches 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 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 2-month-old, temperature 38.3°C (100.4°F), lethargy, poor feeding, and cyanosis
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 68 year old male with end stage neurosyphilis. 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 66 year old male with damage to his thalamus secondary to a cerebral vascular accident.
A 66 year old male with damage to his thalamus secondary to a cerebral vascular accident.
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction? Apply cooling blanket Lower the room temeprature Remove the client's blankets Give client a warm bath
Apply cooling blanket
The cells that are associated with allergic disorders and the inflammation associated with immediate hypersensitive reactions are known as what? Select all that apply. Basophils Nitrous oxide Mast cells Histamines Eosinophils
Eosinophils Basophils Mast cells
What is the most common cause of drug fever? Impaired peripheral heat dissipation by atropine Serotonin syndrome Increased heat production from PTU Hypersensitivity reaction to medication
Hypersensitivity reaction 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? Cerebellum Hypothalmus Cerebral cortex Medulla
Hypothalmus
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: Neutropenia Leukocytosis Lymphadenitis Lymphocytosis
Leukocytosis
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? Eosinophils Neutrophils Platelets Basophils
Neutrophils
A client has a watery fluid leaking from a site of inflammation. The nurse would document this type of exudate as: Serous Suppurative Hemorrhagic Fibrinous
Serous
A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later? T 99.7ºF (37.6°C), P 86/min, R 18/min, BP 130/82 mm Hg T 98.4ºF (36.9°C), P 82/min, R 16/min, BP 106/70 mm Hg T 97.2ºF (36.2°C), P 70/min, R 12/min, BP 114/60 mmHg T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg
T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg
A client is said to be in the chill stage of the fever process when the nurse: administers an antipyretic medication. determines the client will benefit from a cool sponge bath. observes piloerection on the skin. 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: a diagnosis of multiple sclerosis and consequent impaired mobility. poorly controlled blood sugars with small blood vessel disease. chronic obstructive pulmonary disease. congenital heart defects and anemia.
poorly controlled blood sugars with small blood vessel disease.
A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for: Temperature Respirations Urinary output Hypothermia
Temperature
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 fungal infection A mild parasitic infection A mild viral infection A severe bacterial 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 localized fungal infection A mild parasitic infection A mild viral infection
A severe bacterial infection
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? Infections manifest by cognitive changes in older adults. An older adult is sometimes incapable of vasodilation. An older adult is often insensitive to exogenous pyrogens. An older adult's hypothalamus has diminished thermoregulatory ability.
An older adult's hypothalamus has diminished thermoregulatory ability.
The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess?symptom Hypothermia Tissue necrosis Edema Pallor
Edema
The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as: Exudate that is watery fluid, low in protein Exudate that resulted from leakage of red cells Exudate containing large amounts of fibrinogen Exudate containing white blood cells, protein, and tissue debris
Exudate containing white blood cells, protein, and tissue debris
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 Weight gain Fatigue Decreased mental status Depression
Fatigue Decreased mental status Change in fuctional capacity
Inflammation can be either local or systemic. What are the most prominent systemic manifestations of inflammation? Fever, leukocytosis or leukopenia, and the transition phase response Fever, leukocytosis or leukopenia, and the acute phase response Widening pulse pressure, thrombocytopenia, and the recovery phase response Widening pulse pressure, thrombocytopenia, and the latent phase response
Fever, leukocytosis or leukopenia, and the acute phase response
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 Intermittent Relapsing
Intermittent
A 16-year-old girl has broken her arm while snowboarding and is shocked at the amount of swelling at the injury site. Which statement best explains the physiologic rationale for her swelling? Osmotic flow of plasma into the intravascular space causes increased blood volume and interstitial fluid. Migration and proliferation of mast cells, neutrophils, and platelets to the injury site occupy an increased volume of tissue. Loss of plasma proteins causes an increase in interstitial osmotic pressure. Potent vasodilation increases the total volume of vascular space at the site of inflammation.
Loss of plasma proteins causes an increase in interstitial osmotic pressure.
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? Chill Prodrome Flush Defervescence
Prodrome
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 appears to be swollen The ankle is bleeding The ankle is warmer than the unaffected ankle The client's ankle is visibly red
The ankle is warmer than the unaffected ankle The client's ankle is visibly red The client is experiencing pain The ankle appears to be swollen
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 is exhibiting a normal febrile response to a urinary tract infection. The client's absent febrile response indicates absence of an infection. The client's temperature is normal so the client does not have an infection. The client may be exhibiting a blunted or absent febrile response.
The client may be exhibiting a blunted or absent febrile response.
