Inflammation Flashcards
A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5° F temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make?
a. The abdominal incision shows signs of an infection.
b. The patient is having a normal inflammatory response.
c. The abdominal incision shows signs of impending dehiscence.
d. The patient’s physician must be notified about her condition.
b
The nurse assessing a patient with a chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. What would the nurse anticipate being ordered to assess the patient’s systemic response?
a. Serum protein analysis
b. WBC count and differential
c. Punch biopsy of center of wound
d. Culture and sensitivity of the wound
b
A patient in the unit has a 103.7° F temperature. Which intervention would be most effective in restoring normal body temperature?
a. Use a cooling blanket while the patient is febrile.
b. Administer antipyretics on an around-the-clock schedule.
c. Provide increased fluids and have the UAP give sponge baths.
d. Give prescribed antibiotics and provide warm blankets for comfort.
b
A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur?
a. Tertiary intention
b. Secondary intention
c. Regeneration of cells
d. Remodeling of tissues
b
A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient’s WBC count is 15.0 × 106/µL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient’s ability to heal?
a. Imbalanced nutrition: obesity related to high-fat foods
b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking
c. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking
d. Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking
b
Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer?
a. Pack the ulcer with foam dressing.
b. Turn and position the patient every hour.
c. Clean the ulcer every shift with Dakin’s solution.
d. Assess for pain and medicate before dressing change.
c
An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, how should the nurse plan for this patient’s care?
a. Implement a 1-hr turning schedule with skin assessment.
b. Place DuoDerm on the patient’s sacrum to prevent breakdown.
c. Elevate the head of bed to 90 degrees when the patient is supine.
d. Continue with weekly skin assessments with no special precautions.
a
A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are most appropriate (select all that apply)?
a. Acute pain related to tissue damage and inflammation
b. Impaired skin integrity related to immobility and decreased sensation
c. Impaired tissue integrity related to inadequate circulation secondary to pressure
d. Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke
e. Ineffective peripheral tissue perfusion related to arteriosclerosis and loss of blood supply to affected area
b,c
An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
c
Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis?
a. 4-30 bloody stools a day
b. Oral temperature of 39°C
c. Hard, rigid abdomen
d. Urinary stress incontinence
a. 4-30 bloody stools a day
Rationale: frequent, bloody stools are a classic symptom of UC
The nurse is caring for a client with severe inflammation. Which assessment finding would indicate a systemic reaction to inflammation?
a. Erythema
b. Edema
c. Pain
d. Tachycardia
Rationale: Erythema, edema and pain are local symptoms.
d. Tachycardia
Rationale: Erythema, edema and pain are local symptoms.
The nurse is caring for a patient with an infected surgical wound. The surgical team opened the wound to drain the infection; there has been copious amounts of exudate. How should the nurse anticipate healing to occur?
a. Primary intention
b. Secondary intention
c. Tertiary intention
d. Regeneration of cells
c
Rationale: Any wound that is opened after closing will heal by tertiary intention.
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a band count of 11%. What prescribed action should the nurse take first?
a. Obtain cultures of the wound
b. Continue to monitor the wound for drainage
c. Redress the wound with wet-to-dry dressings
d. Begin antibiotic administration
a
Rationale: There is concern for infection of the wound. Need to obtain cultures before beginning antibiotics.
A patient with a systemic bacterial infection feels cold and has shaking chills. Which assessment finding will the nurse expect next?
a. Skin flushing
b. Decreasing blood pressure
c. Rising body temperature
d. Muscle cramps
c
Rationale: Patient feels cold and has shaking chills, which is the body’s way of trying to generate heat in response to a change in the thermostatic set point. The result is a rise the body temperature. Flushing occurs after the infection is eradicated; decreasing blood pressure and muscle cramps are symptoms of heat cramps.
Which surgery for ulcerative colitis results in the patient no longer having anal sphincter control of bowels?
(Inflammation)
a. Total colectomy with permanent ileostomy
