Unit 5 Exam
systemic
Affecting the entire body.
Pathogen
An organism that causes disease
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.
Turgor
Elasticity of the skin
The nurse in the burn unit notes that the patient's skin is dry, pale, and hard. The patient denies pain. What term would the nurse use to document the burn depth? First-degree skin destruction Full-thickness skin destruction Deep partial-thickness skin destruction Superficial partial-thickness skin destruction
Full-thickness skin destruction The appearance is pale and dry or leathery and the area is painless indicate full thickness destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.
Breakthrough pain
Pain that occurs between doses of pain medication
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.
Virulence
The ability of an agent of infection to produce disease.
Vernix caseosa
Waxy or "cheesy" white substance found coating the skin of newborn humans
Localized
affecting one area of the body
Dermis
the underlying subcutaneous or fat tissue
A 65-year-old woman has fallen while sweeping her driveway, sustaining a tissue injury. She describes her condition as an aching, throbbing back. Which type of pain are these complaints most indicative of? Neuropathic pain Nociceptive pain Chronic pain Mixed pain syndrome
Nociceptive pain Nociceptive pain refers to the normal functioning of physiologic systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as dull or aching, and it is poorly localized. Neuropathic pain is described as shooting, tingling, burning, or numbness that is constant in the extremities, as in diabetic neuropathy. Chronic pain lasts longer than 30 days and is characterized by a disease affecting brain structure and function, such as chronic headaches or open wounds. Mixed pain syndromes are caused by different pathophysiologic mechanisms such as a combination of neuropathic and nociceptive pain; this occurs in syndromes such as sciatica, spinal cord injuries, and cervical or lumbar spinal stenosis.
During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development? Vitamins and minerals Protein and calcium Fats and carbohydrates Zinc and potassium
Protein and calcium Adequate stores of protein and calcium allow the developing musculoskeletal system to grow properly. Without the proper vitamins, minerals, and protein, the bones would not develop as they should.
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 is caring for a patient who will be discharged with a pain management plan following a fracture to the forearm. Which of the following should the nurse instruct the patient to do first when in pain? Try not to take your medications until you pain level is at an 8. Take your pain medications when your pain level is at a 3. Try repositioning your arm and applying ice before taking medications. Keep the hand immobile to prevent pain.
Try repositioning your arm and applying ice before taking medication Nonpharmacological measures may prevent the need for medications and may be all that is necessary for proper management. A pain level of an 8 is difficult to manage. Patients should consider taking pain medications when their pain level is under 5 to gain better control over the pain. Elevating the shoulder would be uncomfortable for the patient and this position may increase pain.
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 works just as well as washing with soap and water. 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.
Acrocyanosis
blueness of the extremities
Mongolian spots
bluish purple spots of pigmentation
Immobility
inability to move
Phantom pain
pain felt in a body part that is no longer there
Pruritus
severe itching
Protoza
single-celled eukaryotes, either free-living or parasitic, which feed on organic matter such as other microorganisms or organic tissues and debris
Pandemic
(of a disease) prevalent over a whole country or the world
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
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.
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.
fungus
A single-celled or multicellular organism. Fungi can be true pathogens that cause infections in healthy persons or they can be opportunistic pathogens hat cause infections in immunocompromised persons
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
Acute inflammation Eradication of dead tissue 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.
Which of the following is a priority for a nurse to include in a teaching plan for a patient who desires self-management and alternative strategies? Body alignment and superficial heat and cooling Patient-controlled analgesia (PCA) pump Neurostimulation Peripheral nerve blocks
Body alignment and thermal management are examples of nonpharmacologic measures to manage pain. They can be used individually or in combination with other nondrug therapies. Proper body alignment achieved through proper positioning can help prevent or relieve pain. Thermal measures such as the application of localized, superficial heat and cooling may relieve pain and provide comfort. PCA, neurostimulation, and peripheral nerve blocks are not totally self-managed or alternative therapies, because they are used under the direction of medical professionals
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 obtaining a history from a patient in pain. Which question asked by the nurse will give the most information about the patient's pain? How long have you had this pain? Can you describe your pain? How much medication do you take for the pain? How many times a day do you take medication for the pain?
Can you describe your pain? Because pain is a subjective experience, asking a question that addresses the patient's experience with the pain will elicit more information than the more specific information asked in the other three responses.
The nurse is caring for a patient who sustained a hip fracture and had an open reduction and internal fixation (ORIF) of a hip fracture. The patient will be getting out of bed for the first time postoperatively. Which should the nurse do next? Use a mechanical lift to transfer the patient from the bed to the chair. Check the postoperative orders for the patient's weight-bearing status. Avoid administration of pain medications before getting the patient up. Delegate the transfer of the patient to nursing assistive personnel (NAP).
Check the postoperative orders for the patient's weight-bearing status. The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The nurse should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.
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.
A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete? Gait and balance Speech and hearing Mental alertness Ability to follow directions
Gait and balance When the patient is walking, the nurse is assessing for gait and balance (mobility). Speech, hearing, mental alertness, and the ability to follow directions do not have a bearing on mobility.
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.
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 child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone? Physiologic bonding and growth Speech and hearing development Intellectual and psychomotor function Childhood play interaction
Intellectual and psychomotor function Immobility can cause intellectual and psychomotor deficits because children need to experience mobility to explore the world. Immobility does not have a direct effect on growth, speech, hearing, or play.
The production of which immune cells are increased following exposure to viral antigens? Basophils Eosinophils Lymphocytes Neutrophils
Lymphocytes 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.
Postoperative surgical patients should be given alternating doses of acetaminophen and which medication throughout the postoperative course, unless contraindicated? Antihistamine Local anesthetic Opioids Nonsteroidal anti-inflammatory drug (NSAID)
Nonsteroidal anti-inflammatory drug (NSAID) Unless contraindicated, all surgical patients should routinely be given acetaminophen and an NSAID in scheduled doses throughout the postoperative course. Opioid analgesics are added to the treatment plan to manage moderate-to-severe postoperative pain. A local anesthetic is sometimes administered epidurally or by continuous peripheral nerve block.
Patients who are experiencing immobility often have which of the following emotions? (Select all that apply.) Helplessness Hunger Anger Anxiety Increased communication Improved self-worth
Patients who experience immobility often have psychologic issues such as helplessness, anger, and anxiety. Hunger, increased communication, and improved self-worth are usually the opposite of what is experienced.
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 property of pathogens makes them capable of producing disease once they invade the body? Pathogenesis Transmissibility Susceptibility Virulence
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.
The nurse is caring for a patient who sustained a hip fracture and had an open reduction and internal fixation (ORIF) of a hip fracture. The patient is complaining of pain. Which should the nurse do next? Reposition the patient. Assess the level of pain. Administer of pain medications before getting the patient up. Maintain bed rest.
The nurse should first assess the pain level further before determining which intervention is needed. Repositioning the patient is an intervention and should come after assessment. Administering pain medications is an intervention and should come after assessment. Bed rest is not an intervention for pain management.
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.
The nurse is aware that the best way to prevent the spread of infection when changing the dressing for a wound infected with Staphylococcus aureus? Change the dressing using sterile gloves. Soak the dressing in sterile normal saline. Apply antibiotic ointment over the wound. Wash hands and properly dispose of soiled dressings.
Wash hands and properly dispose of soiled dressings. Hand washing is the best way to prevent the spread of infection. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of infection. Antibiotic ointment is a treatment and will not a prevention strategy.
To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide? (Select all that apply.) Wear sunglasses. Drink plenty of water. Eat plenty of foods high in vitamin K. Apply sunscreen 30 minutes prior to exposure. Consume fish oil and vitamin E.
Wear sunglasses. Apply sunscreen 30 minutes prior to exposure. Consume fish oil and vitamin E. Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and has not been indicated.
Normal flora
are bacteria which are found in or on our bodies on a semi-permanent basis without causing disease.
Linea Negra
dark line of pigmentation from the umbilicus extending to the pubic area during pregnancy
Lanugo
fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn.
Epidemic
A widespread outbreak of an infectious disease.
Melasma
The "mask of pregnancy," a patchy tan-to-dark brown discoloration of the face.
The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement? "Proper care of the skin is important because the immobilized patient does not want to smell bad." "Proper care of the skin is important because the immobilized patient is at high risk for breakdown." "Proper care of the skin is important because the immobilized patient will have many visitors." "Proper care of the skin is important because the immobilized patient will be incontinent."
"Proper care of the skin is important because the immobilized patient is at high risk for breakdown." Skin care is important for an immobilized patient because the patient is prone to skin breakdown from pressure and body fluids. Body odor (smell) is embarrassing to the patient, but it does not pose a risk to the skin. Not every immobilized patient is incontinent. Having visitors does not pose a risk to the skin.
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.
The nurse is teaching a client regarding the usage of antibiotics. Which statement made by the client indicates effective teaching? A."I should not take antibiotics to treat the flu." B."I should take an antibiotic to prevent illness." C."I should stop an antibiotic regimen when I am feeling better." D."I should borrow an antibiotic from a family member or friend in an emergency."
A."I should not take antibiotics to treat the flu." Antibiotics are effective against bacterial infections; therefore the nurse instructs the client to avoid antibiotic use for viral infections such as flu and cold. Antibiotics should not be taken for preventing the disease as they may lead to resistance. The nurse should advise the client to not stop taking an antibiotic when feeling better as doing so may lead to the survival and multiplication of the hardiest bacteria, resulting in resistance. The client should not borrow an antibiotic as the antibiotic may not be appropriate in terms of dose, activity, and illness.
A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next? A.Bending and then straightening their knees B.Bending at the waist and then straightening the back C.Placing one foot in front of the other and then leaning back D.Placing pressure against the client's axillae and then raising their arms
A.Bending and then straightening their knees The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs, the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomic structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.
Which bacteria colonies are commonly found in a client's large intestine? A.Escherichia coli B.Neisseria gonorrhoeae C.Staphylococcus aureus D.Haemophilus influenzae
A.Escherichia coli Escherichia coli are bacteria that are part of the normal flora in the large intestine. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease. Staphylococcus aureus secretes toxins that damage cells and causes skin infections, pneumonia, urinary tract infections, acute osteomyelitis, and toxic shock syndrome. Haemophilus influenzae causes nasopharyngitis, meningitis, and pneumonia.
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 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.
The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply.) Applying over-the-counter lotions to skin that is not broken Assisting the client with frequent turning to prevent pressure ulcers Covering the client who complains of being cold with more blankets Placing a sterile gauze pad over broken skin to contain drainage Assessing a patient complaining of an itching rash
Applying over-the-counter lotions to skin that is not broken Assisting the client with frequent turning to prevent pressure ulcers Covering the client who complains of being cold with more blankets Placing a sterile gauze pad over broken skin to contain drainage All the above options can be delegated to an unlicensed assistive personnel employee except assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.
The nurse educates a client on decreasing the risk of developing antibiotic-resistant infections. Which statement made by the nurse will be most significant? A."Wash your hands frequently." B."Do not skip any dose of your antibiotics." C."Save the unfinished antibiotics for later use." D."Stop taking the antibiotics when you feel better."
B."Do not skip any dose of your antibiotics." Antibiotic-resistant infection develops when the hardiest bacteria survive and multiply. This may happen when a client stops taking an entire course of antibiotics, which leads to infections that are resistant to many antibiotics. Therefore a client should not skip any dose of an antibiotic. Hand washing is required to prevent infections; it is not related to antibiotic-resistant infections. Antibiotics should not be stopped even if the client has started feeling better; the full course of treatment should be taken. Non-compliance in taking the full course of prescribed antibiotics can lead to an antibiotic-resistant infection. It is dangerous to take the unfinished antibiotics at a later time; it may prove fatal if the antibiotics are outdated.
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? A. Optimal functioning of the inflammatory process after an injury B.Fibrous tissue replacing damaged tissue when injury is extensive C.The development of chronic inflammation D.A surgical incision
B.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.
While palpating the skin of a client, the nurse observes pitting edema on the dorsum of the foot. What could be the reason for this condition? A.Endocrine imbalance B.Excessive collagen production C.Fluid and electrolyte imbalance D. Autonomic nervous system stimulation
C.Fluid and electrolyte imbalance Fluid and electrolyte imbalance results in pitting edema of the skin. An endocrine imbalance may result in non-pitting edema. Excessive collagen production leads to increased skin thickness. Stimulation of the autonomic nervous system may result in an increase in skin moisture.
A nurse is assessing a client for the potential for osteoporosis. Which factor in the client's history increases the risk for this disorder? A.Estrogen therapy B.Hypoparathyroidism C.Prolonged immobility D.Excessive calcium intake
C.Prolonged immobility Prolonged immobility results in bone demineralization because there is decreased bone production by osteoblasts and increased resorption by osteoclasts. Estrogen helps prevent bone demineralization. Hypoparathyroidism decreases mobilization of calcium from the bones, thereby reducing the serum level of calcium. Decreased calcium intake or absorption may precipitate osteoporosis.
A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what? A.Promote gluconeogenesis. B.Produce an antiinflammatory effect. C.Promote cell growth and bone union. D.Decrease pain medication requirements
C.Promote cell growth and bone union. There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. Intake of a high protein diet during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain.
A nurse is evaluating a client's understanding regarding postoperative concerns after a mastectomy. Which unanticipated development near and around the incision noted by the client should be reported to her primary healthcare provider? A.Persistent itching B.Decreased sensation C.Swelling with erythema D.Irregular-appearing skin
C.Swelling with erythema Swelling and erythema are signs of infection and should be reported to the primary healthcare provider immediately. Itching is a sign of healing that is expected. Decreased sensation results from the severing of nerves and formation of scar tissue and is expected. There is little subcutaneous fat in the thoracic area, and the skin may be taut at the operative site, appearing irregular; this commonly occurs.
The nurse is caring for a patient who will be discharged following a fracture to the forearm. Which of the following should the nurse include in the discharge instructions? Keep the left shoulder elevated on a pillow or cushion. Keep the hand immobile to prevent soft tissue swelling. Call the health care provider if numbness of the hand occurs. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.
Call the health care provider if numbness of the hand occurs. Numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. Inflammation is a common primary or secondary finding among conditions leading to changes in mobility, from an underlying autoimmune condition to a traumatic injury. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. Elevating the shoulder would be uncomfortable for the patient and this position may increase pain.
The nurse is caring for a patient who has a suspected fracture. Which of the following assessments is most important for the nurse to perform first? Elevate the extremity. Splint the suspected injury. Check the pulses. Verify all immunizations.
Check the pulses. The initial nursing action should be assessment of the neurovascular status of the injured extremity. The next action is to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be collected if there is an open wound.
The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? (Select all that apply.) Cleansing the wound Managing pain Applying a dry sterile dressing Using cold water in the bath
Cleansing the wound Managing pain Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.
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.
A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to perform which actions? (Select all that apply.) Bathe and dry the skin vigorously to stimulate circulation. Keep the head of the bed elevated 30 degrees. Offer nutritional supplements and frequent snacks. Turn the patient at least every 2 hours. Maintain a cooler environment when bathing.
Offer nutritional supplements and frequent snacks. Turn the patient at least every 2 hours The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline. Older adults are more prone to hypothermia if bathed in a cooler environment.
The nurse would explain to a patient that effective treatments for atopic pruritus include which treatments? (Select all that apply.) Oral steroids Topical steroids Oral antihistamines Topical antihistamines Topical petroleum ointment
Oral steroids Topical steroids Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical antihistamines are not usually given, because they are ineffective and may cause further irritation. Petroleum is also ineffective.
Epidermis
Outer layer of skin
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 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.
Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply. Slowed movement Cartilage degeneration Increased bone density Increased range of motion Increased bone prominence
Slowed movement Cartilage degeneration Increased bone prominence The physiologic changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.
The nurse is speaking to a group of teenagers about the risk associated with tanning. Which information should the nurse include when teaching this group? Use a sunscreen with an SPF of at least 8 to 10 for adequate protection. Water-resistant sunscreens will provide good protection when swimming. Increase sun exposure by no more than 10 minutes a day to avoid skin damage. Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).
Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time). The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. Water-resistant sunscreen does not offer complete protection from the sun and is also not considered waterproof. Sunscreen with an SPF of at least 30 is recommended for people at normal risk for skin cancer. The risk of skin cancer does not decrease even when exposure is gradually decreased.
Stephanie is a 70-year-old retired schoolteacher who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. Which of the following options should you suggest for her plan of care, considering her expressed wishes? Using a stationary exercise bicycle and free weights and attending a spinning class Using mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Drinking chamomile tea and applying icy/hot gel Receiving acupuncture and attending church services
Using mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Mind-body therapies are designed to enhance the mind's capacity to affect bodily functions and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Although getting exercise, drinking chamomile tea and applying gels, and receiving acupuncture and attending church services may be beneficial, they are not classified as mind-body therapies in combination as specified in these answer choices.
Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. Pain should be re-assessed at which minimum interval? With each new report of pain Before and after administration of narcotic analgesics Every 10 minutes Every shift
With each new report of pain Before and after administration of narcotic analgesics Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. At a minimum, pain should be reassessed with each new report of pain and before and after administration of analgesics.
Neuropathic
is caused by damage to nerves that share information between the brain and the body. Alamy. Neuropathic pain can develop when the nerves of the somatic (voluntary) nervous system become damaged and transmit sensory signals to the central nervous system in an altered and disordered fashion
Nociceptive
is the sensory nervous system's response to certain harmful or potentially harmful stimuli.
Deconditoned
loss of physical fitness
sebaceous glands
small oil-producing gland present in the skin
Bacteria
unicellular microorganisms that have cell walls but lack organelles and an organized nucleus, including some that can cause disease
Virus
unicellular microorganisms that have cell walls but lack organelles and an organized nucleus, including some that can cause disease
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.
