Ch 3

Question 1

The nurse is assessing a client who is in the prodromal stage of a fever. The nurse anticipates the client will exhibit:

Answer 1

Fatigue (pg. 67)

Question 2

A 24-year-old woman presents with fever and painful, swollen cervical lymph nodes. Her blood work indicates neutrophilia with a shift to the left. She most likely has:

Answer 2

A severe bacterial infection (pg. 63)

Question 3

Which of the following patients is most likely to have impairments to the wound healing process? A patient with:

Answer 3

Poorly controlled blood sugars with small blood vessel disease (pg. 61)

Question 4

An 88-year-old resident of a long-term care home has been suffering from a three-day onset increasing shortness of breath and decreased oxygen saturation. At the hospital, an anterior-posterior chest x-ray and sputum culture and sensitivity has confirmed a diagnosis of bacterial pneumonia, yet the client’s tympanic temperature has not exceeded 99.2 degrees F. The health care team would recognize that whicch of the following phenomena likely underlies this situation

Answer 4

An older adult’s hypothalamus has diminished thermoregulatory ability (pg. 68)

Question 5

The route considering the most accurate to measure a core body temperature is which of the following?

Answer 5

Rectal (pg. 63)

Question 6

The loss of heat from the body through the circulation of air currents is known as which of the following?

Answer 6

Convection (pg. 65)

Question 7

A 2-day post-op patient’s temp was 98.5F at 3pm, at 6pm the patient’s temp is 102.0F. Which of the following actions should the nurse take?

Answer 7

Notify the physician (pg. 63)

Question 8

A Client with pneumonia is admitted with vitals: temp 99.7F, pulse 80bpm, respirations 18/min, and BP 120/80. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later?

Answer 8

T 100.9F, P90bpm, R 20/min, BP 126/80 (pg. 67)

Question 9

A nurse is assisting a patient who has a fever, order lunch. Which of the following would be the most appropriate choice?

Answer 9

toast (pg. 67)

Question 10

Twisted ankle while playing soccer. Which assessment findings are cardinal signs that the client is experiencing inflammation? Select all that apply.

Answer 10

Ankle swollen
ankle is warmer than unaffected ankle
pain
(pg. 53)

Question 11

A client in the acute stage of inflammation will experience vasodilation of the arterioles and congestion in the capillary beds. Would the nurse assess the client’s skin for?

Answer 11

Redness (pg. 53)

Question 12

A client experiencing the early stages of the inflammatory process and develops leukocytosis. The nurse recognizes this as an

Answer 12

Increase in circulating neutrophils (pg. 63)

Question 13

Which clients are showing manifestations of infection

Answer 13

75y/o temp 99.2F, declining mental status, weakness and fatigue
25y/o temp 104F, sweating, shivering, general pain
2m/o, temp 100.4, lethargy, poor feeding, cyanosis
(pg. 67-68)

Question 14

Which of the following patients are at increased risk for hyperthermia? Select all that apply.

Answer 14

Quadriplegic attending outdoor summer event
patient w/ heart disease in non-A/C vehicle
patient w/ schizophrenia taking haloperidol
(pg. 63)

Question 15

Which of the following is an appropriate action by a nurse to take in attempting to decrease a patient’s temperature through conduction?

Answer 15

Apply cooling blanket (pg. 65)

Question 16

Patient w/ fever induced by damage to hypothalamus due to intercranial bleeding. The nurse plans care for the patient w/which of he following types of fever?

Answer 16

Neurogenic (pg. 65)

Question 17

The nurse evaluating the bloodwork results of infected leg ulcer. The white blood cell count is 18,000 cells/uL. The nurse interprets this as?

Answer 17

Leukocytosis (pg. 52)

Question 18

Place the four successive stages of fever in correct order.

Answer 18

Prodomal
Chill
Flush
Defervescence 
(pg. 67)

Question 19

The nurse is reviewing the assessment documentation of a client’s wound and notes “purulent drainage.” interpreted as?

Answer 19

Exudate containing white blood cells, protein, and tissue debris (pg. 60

Question 20

An older adult’s dysfunctional temp regulator function places the client at greatest risk for?

Answer 20

Delayed initiation of appropriate treatment (pg. 68)