Unit 3 Review
A patient presents to the clinic with observable edema and erythema of the left forearm. A brief history reveals no exposure to potential irritating agents. On palpation, the nurse finds the area very warm and tender. What is the most likely cause of the patient's symptoms? An allergic reaction A complement cascade IgE reactions Clonal diversity
A complement cascade is responsible for the dilation of blood vessels and leaking of fluid from the vascular system to the area of insult, resulting in the swelling and redness associated with an inflammatory response. An allergic reaction can cause edema and erythema, but the question does not provide enough information to determine the specific cause of the swelling and redness. IgE is a specific immunoglobulin associated with signs and symptoms of allergic rhinitis. Clonal diversity refers to the maturation process of cells.
After patient teaching, the patient is able to verbalize that which occurrence can delay wound healing after surgery? Adequate arterial blood flow to the wound Supplemental oxygen therapy A healthy diet An increased hospital stay
An increased hospital stay increases the risk for hospital-acquired infections, which can delay wound healing. Adequate arterial blood flow improves, rather than delays, wound healing. Supplemental oxygen can increase wound healing. A healthy diet is important to wound healing.
A nurse explains to the mother of a 1-year-old with a history of frequent ear infections that the primary cause of otitis media in young children is what? Sinusitis Recurrent tonsillitis An inflamed mastoid process An obstructed eustachian tube
An obstructed eustachian tube A blocked eustachian tube impairs drainage and creates negative pressure; when the tube opens, bacteria are pulled into the middle ear.
Cardiovascular disease can be a consequence of which immune function disorder? Type IV hypersensitivity reaction Primary immune deficiency Autoimmune disorder Secondary immune suppression This refers to conditions caused by external immune suppression, e.g. administration of corticosteroid medications.
Autoimmune disorder Cardiovascular disease can be a consequence of autoimmune disorders such as Grave's disease or systemic lupus erythematosus. Option A is incorrect because type IV hypersensitivity disorders cause conditions such as serum sickness. Option B is incorrect because primary immune deficiencies are disorders in which immune components are missing. They affect all body systems and are not organ specific. Option D is incorrect because secondary immune suppression refers to conditions caused by external immune suppression (e.g., administration of corticosteroid medications).
By which method are infections commonly classified? Mode of transmission Trajectory of illness Body system affected Causative microorganism
Causative microorganism Infections are classified by mode of transmission, trajectory of illness, and body system affected. However, the most common method of classification is by causative microorganism.
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? Dyspnea Precordial pain Increased pulse rate Elevated blood pressure
increased pulse rate The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.
The parents of a 4-month-old infant with a diagnosis of acute otitis media and fever ask the nurse about the use of antibiotics to treat this condition. What is the best response by the nurse? "Antiinflammatory medications are recommended for this condition." "Typically antiviral medications are given to treat acute otitis media." "Current practice is to wait 72 hours to see whether the condition resolves." "Antibiotics are recommended for infants younger than 6 months with acute otitis media."
"Antibiotics are recommended for infants younger than 6 months with acute otitis media." All cases of acute otitis media (AOM) in infants younger than 6 months should be treated with antibiotics because of their immature immune systems and the potential for infection with bacteria. Current literature indicates that waiting up to 72 hours for spontaneous resolution is safe and appropriate management of AOM in healthy infants older than 6 months and children. However, the watchful waiting approach is not recommended for children younger than 2 years of age who have persistent acute symptoms of fever and severe ear pain. Antiviral or antiinflammatory medications would not be recommended in an acute case of otitis media.
The nurse is teaching a patient with a new diagnosis of systemic lupus erythematosus (SLE) about her disease. The nurse recognizes that the patient understands the information when making which statement? "I need to avoid getting infections because they will increase the immune response in my body, which can make my SLE worse." "I need to be sure to take all the available immunizations to keep me from getting sick." "Because of my SLE, my immune system is already diminished, so I need to avoid people with the flu." "As long as I take all my prescribed medications, I won't have to make any lifestyle changes as a result of my SLE."
"I need to avoid getting infections because they will increase the immune response in my body, which can make my SLE worse." SLE is a hyperimmunity problem. Pathogens trigger the immune response in the body, which can exacerbate the SLE. Immunizations trigger the immune response in the body to help create antibodies. In patients with autoimmune diseases such as SLE, immunizations can exacerbate the disease. SLE is not the result of immunosuppression. Lifestyle changes are required with most chronic illnesses such as SLE. Patients cannot depend on medications alone.
The nurse is assessing the body temperature of four febrile clients over 4 days. Which client is suffering from remittent fever? Client a 100, 100.4, 100.8, 100.6 Client b 102, 98.5, 103, 99 Client c 103, 101, 104, 102 Client d 102, 98.5, 99.9, 103
Client c In remittent fever, body temperature spikes and falls without a return to normal temperature levels. In client C, the temperature for 4 days is febrile with fluctuations, and the temperature does not return to normal. Client A has sustained fever, with a constant body temperature continuously above 38° C (100.4° F) that has little fluctuation. Client B has intermittent fever, in which the fever spikes interspersed with normal temperature levels. Client D has relapsing fever, which has periods of febrile episodes and periods with acceptable temperature values, often for longer than 24 hours.
A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members? Core rewarming with warm fluids Ambulation to increase metabolism Frequent oral temperature assessment Gastric tube feedings to increase fluids
Core rewarming with warm fluids Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.
Which drug is most appropriate for relieving a painful muscle spasm in the back of a client with osteoarthritis (OA)? Tramadol Hyaluronate Diclofenac epolamine patch Cyclobenzaprine hydrochloride
Cyclobenzaprine hydrochloride is a muscle relaxant administered to relieve painful muscle spasms, especially those resulting from OA of the vertebral column. While tramadol is a weak opioid drug that may also be given to relieve pain in clients with OA, it is not as effective against painful muscle spasms. Hyaluronate is a specific injection for knee and hip pain associated with OA. The diclofenac epolamine patch is used in clients with signs and symptoms of knee OA.
The nurse is caring for a patient with a diagnosis of multiple sclerosis (MS). The nurse should be aware of which associated response? Primary immunodeficiency Secondary immunodeficiency Optimal immune response Exaggerated immune response
Exaggerated immune response MS is an autoimmune disease, which is a form of exaggerated immune response. MS is not a problem of immunodeficiency, nor is it an optimal immune response.
The production of which immune cells are increased following exposure to viral antigens? Basophils Eosinophils Lymphocytes Neutrophils
Lymphocytes are most prominent in inflammatory responses to viral antigens. Basophils are elevated during chronic inflammation/infections, eosinophils during parasitic infections and allergic reactions, and neutrophils during bacterial infections.
Which common pathogens are associated with parasitic infections in humans? Select all that apply. Pseudomonas aeruginosa Tinea pedis Toxoplasmosis Malaria Cryptosporidiosis
Toxoplasmosis Malaria Cryptosporidiosis Pseudomonas aeruginosa is a bacterium and Tinea pedis is a fungus. The pathogens Toxoplasmosis, Malaria, and Cryptosporidiosis are associated with parasitic infections.
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates increased respirations. rapid pulse rate. red, sweaty skin. slow capillary refill.
slow capillary refill. With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.
A patient admitted to an acute care floor has rubor of an area of injury on the left lower extremity. The nurse understands that this redness is caused by vasodilation. extravasation. neutrophils. exudate.
vasodilation The inflammatory process results in rubor, or redness, of an area of insult. The body responds to injury by increasing the blood flow to an area through vasodilation. This allows increased oxygen and more nutrients and appropriate white blood cells to reach the area, isolating the area and beginning the immune response. Extravasation is the movement of fluid from its confined space into the surrounding tissue. Neutrophils are one of the most common types of white blood cells. Exudate is the fluid filled with proteins and white blood cells that moves out of the vascular spaces through extravasation
A patient comes to a clinic with a chief complaint of, "My left arm is red and swollen. It hurts badly enough that I couldn't go to work today." The physician orders computer-assisted tomography (CT) scanning of the left upper extremity. The nurse knows the patient understands the reason for the procedure when he states "I need to have this done because my arm is broken." "The doctor wants me to have this so that the pain will stop." "This will tell you what I did to my elbow because I really don't know what happened." "This test will help to better determine where the injury actually is and how severe it is."
"This test will help to better determine where the injury actually is and how severe it is." Radiographic imaging studies such as CT scans help to determine the location and extent of inflammation within the body. The CT scan will help with diagnosis. The diagnosis is not predetermined. CT scanning does not alleviate pain. Radiography does not necessarily determine a cause of an injury.
A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? Reduce gastric acidity Reduce colonic irritation Reduce intestinal absorption Reduce bowel infection rate
A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is to allow the bowel to rest, not to reduce infection rates.
Which of the following patients is at greatest risk for contracting a primary bacterial infection? A patient with newly diagnosed diabetes mellitus A patient whose lab results reveal leukopenia A patient receiving broad-spectrum antibiotics A patient following laparoscopic cholecystectomy
A patient whose lab results reveal leukopenia The patient with a decrease in the number of white blood cells (leukopenia) is at greatest risk for contracting a primary infection because of a weakened primary defense system. A patient with a diagnosis of diabetes mellitus is at greater risk for infection than a patient who does not have the disease but does not have the greatest risk of the four patients described. The patient receiving broad-spectrum antibiotics already has an infection and is at risk for a secondary infection. The patient who has undergone a surgical procedure is at risk for a bacterial infection but does not have the greatest risk of the patients described. Laparoscopy minimizes invasion and tissue impairment.
Select all the organs from the following list that are part of the immune system. Adenoids Appendix Bone marrow Gallbladder Liver Thyroid gland
Adenoids, Appendix, Bone marrow The lymphoid organs of the immune system are the adenoids, appendix, and bone marrow. Other organs of the immune system include the lymph nodes, thymus gland, tonsils, and spleen.
What functions of leukocytes are involved in inflammation? Select all that apply. Destruction of bacteria and cellular debris Selective attack and destruction of non-self cells Release of vasoactive amines during allergic reactions Secretion of immunoglobulins in response to a specific antigen Enhancement of immune activity through secretion of various factors, cytokines, and lymphokines
Destruction of bacteria and cellular debris and Release of vasoactive amines during allergic reactions Leukocytes such as monocytes and eosinophils are involved in inflammation. Their functions include the destruction of bacteria and cellular debris and the release of vasoactive amines during allergic reactions to limit these reactions. Helper/inducer T-cells and cytotoxic cells selectively attack and destroy non-self cells and secrete immunoglobulins in response to the presence of a specific antigen. B-lymphocytes, or plasma cells, secrete immunoglobulins in response to the presence of a specific antigen. Helper/inducer T-cells are involved in cell-mediated immunity, enhancing immune activity through the secretion of various factors, cytokines, and lymphokines.
The immune system ages as people age. Which immunological changes occur with aging? (Select all that apply.) Decreased immunoglobulin effectiveness Diminished hypersensitivity response Increased number of T lymphocytes Decreased B lymphocyte function Elevated autoantibody synthesis
Diminished hypersensitivity response Decreased B lymphocyte function Elevated autoantibody synthesis Older adults do have diminished capacity for hypersensitivities; therefore they have fewer allergies and immune reactions than when they were younger. B lymphocyte function is decreased secondary to decreased memory cells. Memory cells are important for permanent immunity from many diseases. Decreased B lymphocyte function places older adults at increased risk for infection. Antibodies are directed against the self. As the immune system ages, the ability to differentiate self from nonself is slowed, which can result in antibodies being produced against the self. Option A is incorrect because older adults produce effective immunoglobulins; however, they produce fewer immunoglobulins (antibodies) than younger adults, which places them at increased risk for infections. Option C is incorrect because older adults produce fewer T lymphocytes, which are important for acquired immunity. This places older adults at increased risk for infections.
A client with osteoarthritis is admitted to the hospital for evaluation of a possible hip replacement. To prevent flexion contractures, the nurse recommends that, when in bed, the client should lie in the supine or prone position. The client voices hesitation, stating that these positions are uncomfortable for the knees and hips. What action should the nurse take? Encourage the client to maintain extension for specific periods of time. Allow the client to lie in whatever position is most comfortable. Insert a pillow under the client's knees to relieve discomfort. Place the client in the semi-Fowler position most of the time
Encourage the client to maintain extension for specific periods of time. Flexion contractures of the hips and knees can develop unless some periods of full extension are maintained. The most comfortable position that usually is assumed is one of flexion, which leads to contractures and should be avoided. Placing a pillow under the knees can cause flexion contractures of the hips and knees. Remaining in the semi-Fowler's position can cause flexion contractures of the hips.
The inflammatory process is an anticipated response to tissue injury that produces which desirable outcomes? (Select all that apply.) Initial death of tissues Eradication of dead tissue Formation of scar tissue Acute inflammation Chronic inflammation
Eradication of dead tissue and Acute inflammation Inflammation is a normal and protective response to injury. Four outcomes are possible, two of which are desirable: acute inflammation and eradication of dead tissue. This process returns tissues to their previously uninjured state. The formation of scar tissue occurs when damaged cells cannot be adequately repaired. This is not the most desirable outcome. Chronic inflammation results when tissue destruction continues and is not a desirable outcome. Initial death of tissue leads to death of the host, a very undesirable outcome.
Steroid therapy is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client identifies which times for the medication schedule? At bedtime with a snack Three times a day with meals In the early morning with food One hour before or two hours after eating
In the early morning with food Taking the drug in the early morning mimics usual adrenal secretions; food helps reduce gastric irritation. Diurnal rhythms may be altered, and steroids are ulcerogenic; they should be taken with more than just a snack. Steroids cause gastric irritation and should be taken with food. Although food helps decrease gastric irritation, dividing the dose and taking it throughout the day may alter regular diurnal rhythms; it should be taken in the early morning with food.
The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? Ulnar drift Heberden nodes Swan-neck deformity Boutonnière deformity
Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis. Ulnar drift, swan-neck deformity, and boutonnière deformity occur with rheumatoid arthritis.
A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply. Hips Knees Ankles Shoulders Metacarpals
Hips and knees Osteoarthritis affects the weight-bearing joints (hips and knees) first, because they bear the most body weight. The resulting joint damage causes a series of physiologic responses (release of cytokines and proteolytic enzymes) that lead to more damage. Although the ankles are weight-bearing joints and eventually are affected, the motion in the ankles is not as great as in the hips and knees; thus there is less degeneration. Shoulder joints are not the most likely to be involved first, because these are not weight-bearing joints. Although the distal interphalangeal joints are commonly affected, the remaining interphalangeal joints and metacarpals are not.
Histamine produces which important effects during acute inflammation? (Select all that apply.) Increases vasodilation Enhances vascular permeability Promotes T lymphocyte proliferation Activates neutrophils Mediates early inflammation
Increases vasodilation Enhances vascular permeability Mediates early inflammation Histamine is an important proinflammatory mediator released by mast cells. Similar to serotonin, histamine increases vasodilation, enhances (increases) vascular permeability, and mediates the early acute inflammatory response. Option C is incorrect because interleukin-1 promotes lymphocyte proliferation. Option D is incorrect because platelet-activating factor activates neutrophils.
A client with an acute episode of ulcerative colitis is admitted to the hospital. When reviewing the client's laboratory results, the nurse identifies that the client's blood chloride level is decreased. What is the most efficient way this can be corrected? Low-residue diet Intravenous therapy Oral electrolyte solution Total parenteral nutrition (TPN)
Intravenous therapy ensures a rapid, well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed. Oral electrolyte solution is not a rapid or well-controlled method for correcting electrolyte deficiencies. TPN is not necessary at this time, although it may be used eventually.
A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? Inclusion of transmural involvement of the small bowel wall Higher occurrence of fistulas and abscesses from changes in the bowel wall Pathology beginning proximally with intermittent plaques found along the colon Involvement starting distally with rectal bleeding that spreads continuously up the colon
Involvement starting distally with rectal bleeding that spreads continuously up the colon Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.
Which factor is most basic to the reciprocal relationship between the concepts of thermoregulation and intracranial regulation? Release of epinephrine from the adrenal cortex Effect of thyroxine on the basal metabolic rate Negative feedback function of the hypothalamus Endocrine function of the anterior pituitary
Negative feedback function of the hypothalamus Thermoregulation occurs through a dynamic and complex physiologic process controlled by the hypothalamus that balances heat lost and heat gained. This process involves a negative feedback system in which the hypothalamus activates a series of responses to lower or raise body temperature based on information received by the thermoreceptors located throughout the body. Responses to hypothalamic stimulation are mediated by the endocrine and sympathetic nervous systems, thus making the hypothalamus the most basic link between the concepts of thermoregulation and intracranial regulation.
An acute infection is described as which type of infection? Limited to a specific body area Resolves within several days Spreads throughout the body Incurable in some instances
Resolves within several days Acute infections resolve within several days to a week or so. Localized infection is limited to a specific body area. Systemic infection spreads throughout the body. Chronic infection is incurable in some cases.
Which processes are essential for development of an infection? (Select all that apply) Portal of entry Host Reservoir Microbe Portal of exit Transmission mode
Portal of entry Portal of exit Reservoir Transmission mode The host must be susceptible to infection . Not all microbes cause infection; some are beneficial. Pathogens are microbes that cause infection. All others (portal of entry, reservoir, portal of exit and mode of transmission) are essential processes.
What is the primary purpose of the inflammatory response? Promote healing Facilitate defense Support hemostasis Prevent injury
Promote healing Inflammation is a protective response that minimizes or removes pathologic agents or stimuli that triggered the inflammation, to promote healing.
The concept of immunity is most closely related to which other concepts? (Select all that apply.) Protection Integrity Inflammation Restoration Infection
Protection, Inflammation, Infection The concept of immunity is most closely related to the concepts of protection, because protection is its primary function, and inflammation and infection. It is related to these last two concepts because of overlap between the pathologic, diagnostic, and laboratory tests; clinical findings; and nursing care and outcomes for these and immunity.
Which finding differentiates infection from inflammation? Redness Purulence Swelling Tenderness
Purulence Redness, swelling (edema), and tenderness (pain) are signs of both inflammation and infection. The differentiating characteristic/finding is purulence. Purulence is a sign of infection from invasion of pathogenic microorganisms
The nurse identifies which priority nursing invention for a patient with hyperthermia? Initiating seizure precautions Limiting oral intake Providing a blanket Removing excess clothing
Removing excess clothing The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, so decreasing heat absorption through clothing is the highest priority. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Pouring warm water over the perineum Ensuring the patency of the catheter Removing the catheter within 24 hours Cleaning the catheter insertion site
Removing the catheter within 24 hours Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.
Which condition suppresses immunity and places the patient at increased risk for infection? Stress Hypertension Edema Depression
Stress increases the production of cortisol. Cortisol suppresses immunity and increases the risk for infection. Option B is incorrect because hypertension is not associated with immune suppression. Option C is incorrect because edema does not suppress immunity but could be a sign of inflammation or infection. Option D is incorrect because depression is not associated with immune suppression.
The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections? Immunologic differences between adults and young children Structural differences between eustachian tubes of younger and older children Functional differences between eustachian tubes of younger and older children Circumference differences between middle ear cavity size of adults and young children
Structural differences between eustachian tubes of younger and older children The eustachian tube in young children is shorter and wider, allowing a reflux of nasopharyngeal secretions. Immunologic differences are not a factor in the development of otitis media. There is no difference in the function of the eustachian tube among age groups. The size of the middle ear does not play a role in the occurrence of otitis media in young children.
Which of the following patients is at higher risk for inflammatory reactions? 2-year-old girl with a healthy diet 38-year-old man who is obese 54-year-old woman in menopause 79-year-old man with diabetes
The 79-year-old man is at highest risk for inflammatory reactions among these patients for two reasons, his age and having diabetes. The risk would be high during the first year of life, but this 2-year-old girl has gotten beyond this risk period and she also has the positive factor of a healthy diet. The 38-year-old man is not in a high-risk category because of age but is because of obesity. Although a 54-year-old woman is getting older, being in menopause does not increase the risk for inflammatory reactions.
A woman arrives at the women's health clinic complaining of frequency and burning pain when voiding. The diagnosis is a urinary tract infection. What is important for the nurse to encourage the client to do? Void every 2 hours. Record fluid intake and urinary output. Pour warm water over the vulva after voiding. Wash the hands thoroughly after urinating and defecating.
Wash the hands thoroughly after urinating and defecating. Hand washing is a medical aseptic technique and should limit the spread of microorganisms and help prevent future urinary tract infections if incorporated into the client's health practices. Voiding every 2 hours is unnecessary, but the client should be encouraged to void when the urge occurs. Intake and output need not be measured. Pouring warm water over the vulva after voiding is unnecessary for cystitis; it may be used as a part of perineal care for other problems.
After reviewing the urinalysis reports of a client with a renal disorder, the nurse concludes that the client may have a urinary tract infection. Which urinary laboratory findings enabled the nurse to make this conclusion? Select all that apply. pH: 8.5 Specific gravity: 1.010 Red blood cells: 3/hpf Osmolality: 1500 mOsm/kg (1500 mmol/kg) White blood cells: 6/hpf
The client may have a UTI, as the urinalysis reports show the presence of pH as 8.5 and white blood cells as 6/hpf in the urine. A pH above 8.0 indicates a urinary tract infection; client's is 8.5. The normal level of white blood cells (WBC) in urine should be less than 5/hpf; therefore, the WBC level of 6/hpf indicates UTI The specific gravity of 1.010 indicates a normal finding. The normal level of red blood cells (RBC) is less than 4/hpf; therefore, the RBC levels of 3/hpf indicates normal finding. Osmolality of 1500 mOsm/kg (1500 mmol/kg) indicates tubular dysfunction
A 5-year-old boy with early flu symptoms is at school working with some math blocks. He sneezes into his hand and then continues working with his blocks. An unvaccinated teacher's helper cleans up the blocks when the child leaves them on the table. After touching the blocks, she rubs her nose with her hand. Which represents the most likely mode of transmission? The 5-year-old boy The unvaccinated teacher's helper The hand-to-nose contact The unwashed math blocks
The unwashed math blocks The boy has the flu and sneezes into his hand while at school. When he works with the math blocks, he leaves the flu virus on the toys. The teacher's helper picks up the virus with the blocks. When the parent touches her nose with her hand, the virus enters the susceptible host. The blocks act as the mode of transmission. The boy carries the pathogen, and his sneeze is the portal of exit. The teacher's helper is the susceptible host. The hand-to-nose contact is the portal of entry.
Which statement accurately describes the immunologic mechanism of a hypersensitivity reaction? Type 1 reactions are caused by hypersensitivity to immunoglobulin E (IgE). Poison ivy is an immune-complex mediated reaction. Type II reactions are immediate tissue-specific reactions. Allergic rhinitis is an IgM-mediated hypersensitivity.
Type II reactions are immediate tissue-specific reactions. Option A is incorrect because IgE is the mediator of the response to the allergen; it is not from hypersensitivity to IgE itself. Option B is incorrect because poison ivy is a type IV, cell-mediated reaction, which is a delayed reaction. Option D is incorrect because allergic rhinitis is mediated by IgE.
A client who works manufacturing latex gloves presents with dryness, pruritus, fissuring, and cracking of the skin followed by redness and inflammation about 24 hours after contact. The nurse identifies it as an allergic reaction. Which condition most likely has occurred? Type I allergic reaction Type IV contact dermatitis reaction Immune complex reaction Cytotoxic hypersensitivity reaction
Type IV contact dermatitis reaction Type IV contact dermatitis is caused by the chemicals used in the manufacturing process of latex gloves. It is characterized by dryness, pruritus, fissuring, and cracking of the skin and occurs within 6 to 48 hours of contact. Type I allergic reaction is a response to the natural rubber latex proteins and occurs within minutes of contact with the proteins; skin redness, urticaria, rhinitis, and conjunctivitis are the clinical manifestations. Immune-complex reaction is a type III hypersensitivity. The kidneys, skin, joints, blood vessels and lungs are common sites for deposit. Cytotoxic hypersensitivity reactions involve the direct binding of IgG or IgM antibodies to an antigen on the cell surface and is a type II hypersensitivity.
Which property of pathogens makes them capable of producing disease once they invade the body? Pathogenesis Transmissibility Susceptibility Virulence
Virulence refers to the ability of pathogens to produce disease once introduced into the body. Highly virulent pathogens produce disease when small numbers invade the body; weakly virulent pathogens produce disease only when large numbers invade the body.
An older adult male is discharged after treatment for urinary tract infection. The family members are instructed regarding age-related changes and care to be taken. In the follow-up visit, which statement made by the client's family indicates decreased risk of urinary retention in the client? "I ensure he sips water just before bed." "I respond immediately when he indicates a need to void." "I provide privacy and assistance to him to void." "I encourage him to use the urinal at least every 2 hours."
"I provide privacy and assistance to him to void." The family must help the client while voiding and provide privacy to encourage voiding without embarrassment. These measures will promote voiding and prevent urinary retention in the client. Giving the client water to drink just before bed can increase the risk of nocturia. Immediate response to the client when he needs to void reduces the risk of urinary incontinence. Encouraging the client to use the urinal at least every 2 hours helps the client empty the bladder. Therefore voiding at regular intervals reduces the risk of overflow urinary incontinence.
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action? Places a hypothermia blanket at the bedside Adjusts the bed to the Trendelenburg position Obtains electronic equipment for monitoring the vital signs Secures a pump to administer the ordered intravenous fluids
Adjusts the bed to the Trendelenburg position It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.
The nurse instructs a human immunodeficiency (HIV)-positive client about ways to prevent infections. During a follow-up visit, which statement made by the client indicates a need for more education? "I reuse cups after washing them." "I wash my hands with tap water after gardening." "I rinse my toothbrush in liquid laundry bleach every week." "I wash my armpits, groin, and genitals with antimicrobial soap twice a day."
An HIV-positive client should refrain from digging in soil and performing gardening activities. Soil contains several infectious microorganisms. In unavoidable circumstances, the client should wear gloves and wash hands thoroughly with antimicrobial soap after gardening. The client should refrain from reusing cups without washing them. Weekly rinsing of a toothbrush in liquid laundry bleach helps prevent infectious pathogens from accumulating on the brush. The armpits, groin, and genitals tend to house higher amounts of microorganisms and should be cleaned twice a day with antimicrobial soap.
Immune components have specific functions. Which immune component provides specific protection against bacterial and viral pathogens? Cytotoxic T lymphocytes Serum complement B cell immunoglobulins Phagocytic macrophages
B cell immunoglobulins Immunoglobulins produced by B cells provide humoral immunity and are the primary defense against bacterial and viral infections. Option A is incorrect because T lymphocytes are part of cellular or cell-mediated immunity. Cytotoxic T lymphocytes attack and kill antigens directly but are not the primary defense mechanism against viral and bacterial infections. Option B is incorrect because the serum complement system contributes to the immune response by amplifying and increasing the systems efficiency and efficacy, but the system is not the primary defense mechanism against viral and bacterial infections. Option D is incorrect because phagocytic macrophages are part of innate immunity and the first line of defense during an immune reaction. They are not, however, the primary defense mechanism against viral and bacterial infections.
Which important proinflammatory mediator is responsible for initiating neutrophil and macrophage chemotaxis to the site of tissue injury during inflammation? Leukotrienes Bradykinins Transforming growth factor Complement proteins
Complement proteins Complement proteins are very important, especially C3a, C4a, and C5a, because they initiate chemotaxis (movement) of neutrophils and macrophages toward the site of tissue injury during inflammation.
The nurse is reviewing the erythrocyte sedimentation rate (ESR) of a patient to determine which significant finding? Determines specific causes of inflammation. Identifies the location of inflammation within the body. Confirms the nonspecific presence of inflammation. Indicates a diagnosis of systemic lupus.
Confirms the nonspecific presence of inflammation. An elevated ESR is indicative of the presence of inflammation in the body. Proteins produced during the inflammatory process adhere to red blood cells, causing them to be heavier and settle out of blood samples at a faster rate than normal. The ESR does not identify specific causes of inflammation and does not determine a specific location of inflammation. The ESR is a nonspecific indicator of inflammation.
The nurse is completing an admission assessment of a new patient to the unit. The nurse notes a long, thin, fading scar on the patient's abdomen in the right lower quadrant. What is the best explanation for the scar's appearance? Optimal functioning of the inflammatory process after an injury Fibrous tissue replacing damaged tissue when injury is extensive The development of chronic inflammation A surgical incision
Fibrous tissue replacing damaged tissue when injury is extensive Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged too extensively for the body to replace damaged tissue with identically functioning tissue after removal of injurious agents and pathogens. Optimal functioning of the inflammatory process will result in regeneration of tissue that functions identically to the damaged and replaced tissue. Chronic inflammation can result in fibrous, or scar, tissue, but that scar tissue production is continuous as the inflammation continues. Fibrous tissue production can result from many different kinds of injuries, not just surgical wounds.
The nurse is teaching a class of junior high school students about infection control through effective hand washing. Which statement made by a student indicates the need for further teaching? "Hand sanitizer works just as well as washing with soap and water." "If I sing the song "Happy Birthday" twice through while scrubbing my hands, that should be long enough." "I need to read the label on the hand sanitizer to be sure that it's at least 60% alcohol." "We should all wash our hands before eating lunch every day."
Hand sanitizer does not work as well as soap and water, because it is not effective against all pathogens or in all situations. For example, hand sanitizer should not be used when hands are visibly dirty. Repeating the song "Happy Birthday" twice takes about 20 seconds, which is how long hands should be rubbed together with soap. Hand sanitizer needs to be at least 60% alcohol to be effective. Hand washing before eating is recommended by the Centers for Disease Control.
A patient is in contact isolation for a bacterial infection. The nurse is going to implement which of the following interventions for this patient? Prevent all visitors from entering the room at any time during hospitalization. Use personal protective equipment only when knowingly coming into contact with pathogens. Help to ensure adequate social interaction and support. Communicate with the patient over the call light whenever possible.
Help to ensure adequate social interaction and support. Frequently, patients in contact isolation do experience a decrease in social interaction because of the isolation. The nurse must help provide adequate social stimulation for the patient. Frequently, this is done by educating the family and friends regarding isolation practices. Isolation does not mean that the patient cannot have visitors. Visitors must be educated on how to maintain the contact isolation while with the patient, especially hygiene guidelines. Personal protective equipment must be used when entering the room of a patient in contact isolation. Nurses and visitors do not always know when they will come into contact with a pathogen, especially if it is highly virulent. The patient in contact isolation should have regular face-to-face contact with the nurse. The nurse should not use the call light system to communicate with a patient in isolation any more than any other patient.
Which type of hypersensitivity reaction is present in a client with a body temperature of 102 °F, severe joint pain, rashes on the extremities, and enlarged lymph nodes from serum sickness? Delayed reaction Cytotoxic reaction Immediate reaction Immune complex-mediated reaction
Immune complex-mediated reaction Serum sickness is a type III immune complex-mediated reaction. A delayed reaction is a type IV hypersensitivity reaction that may include poison ivy skin rashes, graft rejection, and sarcoidosis. A cytotoxic reaction is a type II hypersensitivity reaction that includes autoimmune hemolytic anemia, Goodpasture syndrome, and myasthenia gravis. An immediate reaction is a type I hypersensitive reaction that includes allergic asthma, hay fever, and anaphylaxis.
A nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching by the nurse is effective? Select all that apply. Orange juice Creamed soup Jelly sandwich Lean roast beef Scrambled eggs
Jelly sandwich Lean roast beef Scrambled eggs A jelly sandwich is low in residue and therefore is less irritating to the colon than other foods. Lean roast beef is low in residue and therefore is less irritating to the colon than other foods. Eggs are low in residue and therefore are less irritating to the colon than other foods. Orange juice contains cellulose (fiber), which is not absorbed and irritates the colon. Milk in creamed soup contains lactose, which is irritating to the colon.
The registered nurse instructs the nursing student about caring for a hospitalized client with a human immunodeficiency (HIV) infection. Which action made by the nursing student indicates effective learning? Keeping fresh flowers in the client's room Encouraging the client to eat fresh fruits and vegetables Keeping a dedicated disposable glove box in the client's room Changing gauze-containing wound dressings every other day
Keeping a dedicated disposable glove box in the client's room A client with an HIV infection is at a high risk of contracting infections. Therefore the nurse should keep a dedicated disposable glove box in the client's room and avoid using supplies from a common area. The nurse should refrain from keeping potted plants and flowers in the client's room because they act as source of potentially infectious bacteria and fungi. A client with an HIV infection should be discouraged from consuming raw fruits and vegetables and should be given well-cooked food to reduce risk of food borne pathogens. In order to reduce the risk of infections, the nurse should change gauze-containing wound dressings every day.
While caring for a client with urinary tract infection, the nurse manager delegated the work of administering oral medications. Which delegatee would be appropriate for this task? Select all that apply. Registered nurse (RN) Patient care associate (PCA) Licensed practical nurse (LPN) Licensed vocational nurse (LVN) Unlicensed assistive personnel (UAP)
Licensed practical nurse (LPN) Licensed vocational nurse (LVN) Medications can be administered by the licensed practical nurse (LPN) or licensed vocational nurse (LVN) if the task is not complicated. The registered nurse (RN) administers intravenous fluids and medications. Patient care associates (PCA) perform basic hygiene for the client. Unlicensed assistive personnel (UAP) can record vital signs under the supervision of the delegator.
How would wrapping a blanket around a young child affect thermoregulation? Mark any that apply. Absorbs cold from the body surface Limits heat loss from convection Conserves heat through vasoconstriction Increases heat loss from conduction Decreases heat loss through radiation
Limits heat loss from convection Decreases heat loss through radiation Convection refers to the loss of heat as a result of air currents moving across the body surface, which cause warm air at the surface to be replaced by cooler air. Radiation refers to heat loss through electromagnetic waves that emit heat from skin surfaces to the air. The degree of heat loss from radiation is a function of both the difference between ambient air and skin temperature and the amount of skin exposure. Wrapping a blanket around a child limits skin exposure, thereby decreasing heat loss through radiation, and preventing cool air currents from moving across the body surface, thereby limiting heat loss through convection.
Why is inflammation often confused with infection? Prostaglandin hormone mediates both. Purulent drainage is frequently present. Many pathophysiologic processes are shared. They produce comparable immune dysfunction.
Many pathophysiologic processes are shared. Inflammation and infection are commonly confused because many of the pathophysiologic processes associated with one are also found with the other; they overlap. Option A is incorrect because prostaglandin is a proinflammatory hormone that mediates late stages of acute inflammation. Infections are not mediated by such hormones. They are only involved in infections because inflammation occurs when infection occurs. Option B is incorrect because purulent drainage is a sign of infection, but does not occur from inflammation. Option D is incorrect because infection can overwhelm and damage the immune system very quickly (septic shock). Acute inflammation is a protective response. Chronic inflammation, over time, does damage tissue and can be detrimental to the immune system. However, these processes are not comparable.
The nurse is reviewing the problems that may occur after frequent episodes of otitis media in infants. What complications may be precipitated by this infection? Select all that apply. Mastoiditis Heart failure Hearing loss Gastroenteritis Bacterial Meningitis
Mastoiditis, hearing loss and bacterial meningitis Mastoiditis is an inflammation of the mastoid gland; it may occur as a complication of otitis media because of the mastoid gland's proximity to the ear. Hearing loss is a common complication of otitis media; the child should be assessed frequently for this problem. The closeness of the infant's structures results in infections of surrounding organs; meningitis is a complication of otitis media.
The nurse is caring for a patient experiencing an immune response. She assesses the patient for development of a hyperimmune response while knowing that cytotoxic T cells are responsible for which action? May kill healthy cells along with foreign antigens. Are the most prevalent type of T lymphocyte. Can suppress the immune response. Diminish dendritic cell function.
May kill healthy cells along with foreign antigens. Cytotoxic T lymphocytes can kill healthy tissue along with antigens. Suppressor T cells help to keep cytotoxic T cells in check. Helper T cells are the most prevalent type of T lymphocyte, not cytotoxic cells. Cytotoxic T lymphocytes do not suppress the immune response but are a factor in optimal immune functioning. Suppressor T lymphocytes help to suppress the function of cytotoxic cells. Dendritic cell function enhances cytotoxic T lymphocyte functioning.
What treatment does the nurse anticipate that the practitioner will recommend? Ear drops Myringotomy Mastoidectomy Steroid therapy
Myringotomy is a surgical opening into the eardrum to permit drainage of accumulated fluid associated with otitis media. Ear drops are not used because they will obscure the view of the tympanic membrane. Removal of the mastoid will not relieve pressure within inflamed ears. Antibiotics, not steroids, are used for an infectious process.
A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia? Stupor Erythema Increased anxiety Rapid respirations
Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.
On which basis is fever differentiated from hyperthermia in clinical practice? Diurnal pattern of temperature elevation Serum levels of interleukin-1 Coexistent fluid and electrolyte imbalance Underlying cause
Underlying cause Fever is differentiated from hyperthermia by the underlying cause. Hyperthermia exists when the body temperature rises above 37.6 C with an unchanged hypothalamic set point. Fever is also an elevation of body temperature but with an increase in hypothalamic set point caused by release of interleukin-1 and tumor necrosis factor from white blood cells. Fever is usually associated with an inflammatory process but can also be caused by drugs and tumors.
