Inflammation & Immune Response
A client has redness, warmth, and swelling at an IV site. Which physiologic change best explains these findings?
vasodilation and increased capillary permeability
A nurse reviews labs for a client with fever and notes an elevated WBC count with neutrophil predominance. The nurse suspects what type of infection?
an acute bacterial infection
A client with pneumonia has chills and shivering. Why is the client shivering despite having a fever?
an increased hypothalamic set point
A client presents with slurred speech, shivering, and confusion. Which condition does the nurse suspect?
hypothermia
A patient describes sharp, immediate pain after touching a hot stove. Which nerve fibers transmitted this pain?
A-delta fibers
A nurse explains that inflammation helps prevent infection at an injury site. Which action of inflammation supports this?
walling off the pathogen and activating phagocytes
A client’s ESR is elevated. How should the nurse interpret this result?
evidence of inflammation
A nurse administers acetaminophen for fever. Which physiologic effect causes the temperature to decrease?
lowering the hypothalamic set point
Why is oral temperature an unreliable measurement in hypothermic patients?
peripheral vasoconstriction affecting accuracy
A patient reports aching, burning pain that persists after injury. Which fibers are responsible?
C fibers
A client with a laceration has neutrophils migrating out of the bloodstream and into the tissue. Which phase of inflammation is occurring?
the cellular phase
A patient with worsening infection has rising CRP levels. What does this trend indicate?
increasing systemic inflammation
Which finding helps the nurse differentiate fever from hyperthermia?
response to antipyretics
A hypothermic patient suddenly stops shivering. What does this indicate?
worsening hypothermia
Why are NSAIDs effective for inflammatory pain?
inhibition of prostaglandin synthesis
A patient’s wound has been inflamed for several weeks with ongoing tissue damage. The nurse recognizes this as which type of inflammation?
chronic inflammation
Which assessment finding best suggests progression from localized infection to sepsis? (3)
hypotension, elevated lactate, and altered mental status
A client with heat stroke does not respond to acetaminophen. Which intervention is the priority?
active cooling measures
Which nursing action is contraindicated in moderate to severe hypothermia?
vigorous extremity massage
A client has uncontrolled acute pain. Which physiologic effect does the nurse anticipate?
increased heart rate and blood pressure from stress response
Which finding best indicates inflammation has progressed to infection?
pathogen invasion with systemic signs (fever, leukocytosis)
A client has recurrent viral infections despite normal antibody levels. Dysfunction of which immune cell is most likely?
T cells or natural killer cells
A temperature of 106°F (41°C) places a client at greatest risk for which complication?
organ damage or neurologic injury
A hypothermic patient develops a prolonged QT interval. The nurse is most concerned about which complication?
life-threatening dysrhythmias
Why is early pain management critical in preventing chronic pain?
preventing prolonged C-fiber stimulation and central sensitization