Unit 2:Ch 9 (Porth's 5th Ed) - Inflammation, Tissue Repair, and Wound Healing

Question 1

A 23-year-old man has received a recent diagnosis of appendicitis following 24 hours of acute abdominal pain. The nurse providing care for the man is explaining that while unpleasant, the inflammation of his appendix is playing a role in his body’s fight against the underlying infectious process. Which of the following teaching points should the nurse eliminate from his teaching to the patient?
A)“Inflammation can help to remove the body tissue cells that have been damaged by infection.”
B)“Inflammation will start your body on the path to growing new, healthy tissue at the site of infection.”
C)“Inflammation helps your body to produce the right antibodies to fight the infection.”
D)“Inflammation ultimately aids in eliminating the initial cause of the cell injury in your appendix.”

Answer 1

Ans: C
Feedback:
Antibody production is not a noted component of the inflammatory response. Removing damaged cells, generating new tissue, and eliminating the cause of cell injury are all documented components of the inflammatory response.

Question 2

A patient presented to the emergency department of the hospital with a swollen, reddened, painful leg wound and has been diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) cellulitis. The patient's physician has ordered a complete blood count and white cell differential of the following blood components would the physician most likely anticipate to be elevated?
A)Basophils
B)Eosinophils
C)Platelets
D)Neutrophils

Answer 2

Ans: D
Feedback:
Increased neutrophils are associated with inflammation in general and bacterial infections in particular. Platelets play a role in inflammation, but their levels would not rise to the same extent as would neutrophils’. Eosinophils are not strongly associated with bacterial infection, and basophils would not increase to the same degree as neutrophils.

Question 3

A 16-year-old girl has broken her arm while snowboarding. When she arrives at hospital, she is shocked at the amount of swelling at the injury site. Which of the following statements best explains the physiological rationale for her swelling?
A) Migration and proliferation of mast cells, neutrophils, and platelets to the injury site occupy an increased volume of tissue.
B) Potent vasodilation increases the total volume of vascular space at the site of inflammation.
C) Osmotic flow of plasma into the intravascular space causes increased blood volume and interstitial fluid.
D) Loss of plasma proteins causes an increase in interstitial osmotic pressure

Answer 3

Ans: D
Feedback:
Swelling is the result of plasma proteins leaving the interstitial space, resulting in increased osmotic pressure of interstitial fluid and movement of fluid into tissues. Blood components, vasodilation, nor increased intravascular volume accounts for swelling

Question 4

Which of the following phenomena best accounts for the increased presence of leukocytes at the site of inflammation?
A) Existing leukocytes stick to the epithelial cells and move along blood vessel walls.
B) Increased numbers of leukocytes are released into circulation via cytokine stimulation.
C) Leukocytes are osmotically drawn from circulation into the interstitial space as a result of swelling.
D) Epithelium expresses leukocyte stimulation factors in response to cell injury

Answer 4

Ans: A
Feedback:
During inflammation, leukocytes accumulate at the point of epithelial contact in the processes of margination, adhesion, and transmigration. This is not directly achieved by a way of increased leukocyte production or release, nor by osmotic pressure. The epithelium does not produce leukocyte stimulation factors.

Question 5

When explaining the final stages of the inflammatory response to pathogens, the nurse will educate the patient about
A) how the body can kill the pathogen by generating toxic oxygen and nitrogen products producing such things as nitric oxide and hydrogen peroxide.
B) margination, which is a process whereby white cells (leukocytes) stick to the endothelium and accumulate along the blood vessel.
C) the increase in vascular permeability, which lets fluids leak into the extravascular tissues.
D) the promotion of tissue regeneration whereby monocytes and macrophages produce potent prostaglandins and leukotrienes

Answer 5

Ans: A
Feedback:
The latter stages of phagocytosis results in intracellular killing of pathogens accomplished by several mechanisms, including toxic oxygen and nitrogen products, lysozymes, proteases, and defensins. The metabolic burst pathways generate toxic oxygen and nitrogen products (i.e., nitric oxide, hydrogen peroxide, and hypochlorous acid). Margination is one of the early stages of the inflammatory response. Vascular changes occur with inflammation but are prior to the final stage. Macrophages arrive within hours at the inflammation site.

Question 6

A deficiency in which of the following would result in an inhibition of the inflammatory response?
A) Histamine
B) Helper T cells
C) B cells
D) Vitamin K

Answer 6

Ans: A Feedback:

Histamine is a key mediator in the inflammatory system, unlike helper T cells, B cells, or vitamin K.

Question 7

When educating a patient with a wound that is not healing, the nurse should stress which of the following dietary modifications to ward off some of the negative manifestations that can occur with inflammation?
A) Increase the amount of calcium in the diet, especially drinking milk and eating cheese.
B) This is the one time whereby you should eat more fat (both polyunsaturated and saturated), so you can absorb more fat soluble vitamins.
C) Since there is a loss of plasma proteins, you should increase your intake of organ meats like liver.
D) Increase your intake of oily fish and fish oil so that you will increase absorption of omega-3 polyunsaturated fatty acids.

Answer 7

Ans: D
Feedback:
Dietary modification of the inflammatory response through the use of omega-3 polyunsaturated fatty acids, specifically eicosapentaenoic acid and docosahexaenoic acid, which are present in oily fish and fish oil, may be effective in preventing some negative manifestations of inflammation.

Question 8

Tumor necrosis factor-a and IL-1 are major cytokines that mediate inflammation. If the patient is developing a systemic response to an infection, the nurse will likely assess which of the following clinical manifestations? Select all that apply.
A) Elevated temperature
B) Hypertension
C) Tachycardia
D) Decrease in urine output
E) Anorexia

Answer 8

Ans: A, C, E Feedback:
IL-1 and TNF-a are mediators of the acute-phase responses associated with infection or injury. Features of these systemic responses include fever (elevated temperature), hypotension, tachycardia (increased heart rate), anorexia, increase in neutrophil count, and increased levels of corticosteroid hormones

Question 9

63-year-old woman has begun a diet that purports to minimize the quantity and effects of free radicals in her body. What physiological processes could best underlie her care provider’s teaching about her new diet?
A) Free radicals act as direct mediators in the inflammatory process.
B) Free radicals inhibit the inflammatory response, limiting preadaptive response to infection.
C) Free radicals increase cytokine expression and adhesion molecule levels, resulting in increased inflammation.
D) Free radicals contribute to atherosclerosis and decreased immune response.

Answer 9

Ans: C
Feedback:
Free radicals are thought to bring about an inappropriate inflammatory response by increasing cytokines and numbers of adhesion molecule. They are not direct mediators of inflammation and are not associated with decreased immune response but rather inappropriate inflammation. Free radicals are not associated with inhibition of the inflammatory response.

Question 10

A nurse is changing the wound dressing on the coccyx-region pressure ulcer of an immobilized patient. The existing dressing is saturated with both watery, clear discharge and foul, gray-colored liquid. Which of the following entries in the patient’s chart best captures this?
A) “Large amounts of suppurative and serous exudates noted”
B) “Purulent discharge fibrinous exudate on existing dressing”
C) “Abscess activity noted to coccyx wound”
D) “Plasma proteins and membranous exudates present on existing dressing”

Answer 10

Ans: A
Feedback:
Serous discharge is clear and low in plasma proteins, while suppurative, or purulent, exudates are a mass of degraded cells. An abscess would be physically contained with no discharge, and the exudate is neither fibrinous nor membranous.

Question 11

Which of the following aspects of a patient's site of inflammation would help the care provider rule out chronic inflammation?
A) High levels of macrophages
B) Increased neutrophils
C) Proliferation of fibroblasts
D) Infiltration of lymphocytes

Answer 11

Ans: B
Feedback:
Chronic inflammation lacks the sudden and marked proliferation of neutrophils that is associated with acute inflammation. Chronic inflammation is associated with increased presence and action of fibroblasts, macrophages, and lymphocytes.

Question 12

In the ICU, a patient has been diagnosed with sepsis due to a bacterial invasion. The human body usually responds to infections by developing an uncontrolled inflammatory response with large production and release of inflammatory cytokines such as IL-1 and TNF-a. The nurse will note which of the following clinical manifestations in this septic patient as a result of the activation of these cytokines? Select all that apply.
A) Excessive interstitial edema related to increased vascular permeability
B) Decreased cardiac output resulting from myocardial depression
C) Increased respiratory rate with crackles heard throughout all lung fields
D) Excessive bleeding from bowels and bladder
E) Lower blood pressure due to intravascular fluid loss

Answer 12

Ans: A, B, E
Feedback:
SIRS (systemic inflammatory response syndrome) can develop as a result of large quantities of microbes entering the blood, resulting in the release of enormous quantities of inflammatory cytokines. They cause generalized vasodilation (hypotension), increased vascular permeability (fluid loss into the tissues), intravascular fluid loss (dehydration with low urine output and low BP), myocardial depression (decreased cardiac output), and circulatory shock.

Question 13

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
A) a mild parasitic infection.
B) a severe bacterial infection
C) a mild viral infection.
D) a severe fungal infection.

Answer 13

Ans: B
Feedback:
Fever and painful, palpable lymph nodes are nonspecific inflammatory conditions; leukocytosis is also common but is a particular hallmark of bacterial infection.
Neutrophilia also indicates a bacterial infection, whereas increased levels of other leukocytes would indicate other etiologies. The shift to the left––the presence of many immature neutrophils––indicates that the infection is severe, because the demand for neutrophils exceeds the supply of mature cells.

Question 14

Which of the following patients would have a very poor response related to tissue regeneration of his or her injured area?
A) A 21-day-old infant undergoing a diaphragmatic hernia repair
B) A 54-year-old male who had a massive MI 4 days ago and came to the ED today for treatment
C) A 73-year-old female who is undergoing lithotripsy for kidney stones
D) A 33-year-old athlete undergoing surgery to repair a torn MCL in his right knee

Answer 14

Ans: B
Feedback:
Permanent or fixed cells cannot undergo mitotic division. The fixed cells include nerve cells, skeletal muscle cells, and cardiac muscle cells.

Question 15

A hospital patient has a large, superficial wound on her elbow that was the result of shearing action when she was moved up in her bed. The patient’s husband mentions that the wound looks infected and irritated because the wound bed is completely red. Which of the following responses would be inappropriate?
A) “Even though it is red, it doesn’t mean that the wound is infected.”
B) “The red areas show that there is enough circulation to facilitate healing.”
C) “Those are fresh blood vessels that are a sign of healthy healing.”
D) “A thin sheet of blood clotting is actually desirable and not a sign that your wife’s wound is infected.”

Answer 15

Ans: D
Feedback:
Granulation tissue indicates sufficient circulation and angiogenesis associated with healthy wound healing. Granulation tissue consists of new blood vessels, not clotted cellular components.

Question 16

Which of the following processes would most likely be considered an anomaly during the cellular phase of inflammation?
A) Platelet aggregation
B) Vasoconstriction
C) Migration of phagocytic white cells
D) Macrophage activity

Answer 16

Ans: B
Feedback:
While vasoconstriction is a component of the immediate inflammatory response, the later cellular phase of inflammation is accompanied by vasodilation. Platelet aggregation, vasoconstriction, migration of phagocytic white cells, and macrophage activity are all associated with the cellular phase.

Question 17

A patient who is recovering from burn injuries is discussing his prognosis with aphysician. Which of the following teaching points about expectations for healing should the physician include?
A)“Once your healing is complete, your skin will be just as strong as before your accident.”
B)“You may find that the scar is a bit smaller than the area of the wound.”
C)“You’ll find that your new tissue is more elastic and fragile than the rest of your skin.”
D)“The final remodeling phase of healing may last up to 3 months in your case.”

Answer 17

Ans: B
Feedback:
Scars are often smaller than the original area of the wound. There is nearly always an accompanying loss of strength and elasticity, and remodeling can take over 6 months.

Question 18

Of the following list of patients, who would likely benefit the most from hyperbaric oxygen therapy?
A)A trauma patient who developed Clostridium spp., an anaerobic bacterial infection in his femur
B)A patient who developed a fistula between her bowel and vagina following cervical cancer surgery
C)A school-aged child who fell on gravel and has terrible road rash
D)A football player who has torn a meniscus in his knee for the third time this year

Answer 18

Ans: A
Feedback:
Hyperbaric oxygen is a treatment that has demonstrated improved wound healing in multiple types of injuries. It enhances wound healing by a number of mechanisms, including the increased killing of bacteria by neutrophils, impaired growth of anaerobicbacteria, and the promotion of angiogenesis.

Question 19

Which of the following patients is most likely to have impairments to the wound-healing process? A patient with
A)chronic obstructive pulmonary disease.
B)a diagnosis of multiple sclerosis and consequent impaired mobility.
C)poorly controlled blood sugars with small blood vessel disease.
D)congenital heart defects and anemia.

Answer 19

Ans: C
Feedback:
Diabetes mellitus is strongly associated with impaired wound healing. The other noted pathologies are less causative of deficiencies in the healing process

Question 20

A 79-year-old female resident of an assisted living facility receives care from a community nurse on a regular basis for the treatment of a chronic venous leg ulcer. Which of the following factors would the nurse be most justified in ruling out as a contributing factor to the client’s impaired wound healing?
A)A lower skin collagen content than in younger adults
B)Decreased fibroblast synthesis
C)Slow reepithelialization
D)Decreased antibody levels

Answer 20

Ans: D
Feedback:
Older adults do not normally have diminished antibody levels. Low collagen levels, decreased fibroblast activity, and slow reepithelialization are common impediments to wound healing in the elderly

Question 21

The medical team is assessing a newly admitted patient who is hypothermic following anight spent lost on a ski slope. The health care professionals would recognize that whic hof the following phenomena most likely contributed to minimizing the client’s heat loss in a cold environment?
A)The high heat conductivity of subcutaneous tissue protected against core heat loss.
B)Increased blood flow to the outer shell prevented superficial freezing and loss of heat.
C)The tissue thickness of the outer shell increased and preserved heat.
D)Shell temperature dropped, minimizing the temperature variance between the core temperature and environmental temperature.

Answer 21

Ans: C
Feedback:
The thickness of the outer shell is modifiable in response to the environmental temperature and can be increased through decreased blood flow. Subcutaneous tissue provides protection due to its low, not high, conductivity. Blood flow decreases to the outer shell in low temperatures, and the lowering of the shell temperature does not necessarily minimize heat loss.

Question 22

In the ICU setting, a patient transported from surgery following open heart bypass grafting will likely have his core temperature measured by a/an
A)rectal tube inserted to prevent evacuation from bowels while recovering from anesthesia.
B) temperature probe taped behind his ear.
C)esophageal flexible thermometer monitoring aorta distention.
D)pulmonary artery catheter being used to measure cardiac output.

Answer 22

Ans: D
Feedback:
Core temperature may be obtained by a rectal tube, by using an esophageal flexible thermometer, from a pulmonary artery catheter used for thermodilution measurement of cardiac output, or from a urinary catheter with a thermo sensor that measure s the temperature of urine in the bladder. Since CABG patients have their core temperature decreased to the 80s, the pulmonary artery catheter is the best choice for measuring core temperature while they are still under the influence of anesthesia.

Question 23

A nurse is providing care for several clients on a neurological unit of a hospital. I in which of the following clients would the nurse be justified in predicting a problem with thermoregulation?
A)A 66-year-old male with damage to his thalamus secondary to cerebral vascular accidents
B)A 22-year-old male with damage to his cerebellum secondary to motorcycle accidents
C)A 68-year-old male with end-stage neurosyphilis
D)A 45-year-old female with a T8 fracture secondary to a diving accident

Answer 23

Ans: A
Feedback:
The thalamus is involved in the sensation and regulation of body temperature. Syphilis, a T8 fracture, and damage to the cerebellum would unlikely manifest by difficulties with thermoregulation.

Question 24

An 8-year-old boy has fallen through the ice while skating on a frozen pond. By the time paramedics arrive, the boy has been removed from the water by his friends, but his core body temperature is 31.1°C (88.0°F). The responders would recognize that which of the following physiological processes would have been active during the boy’s accident?
A)Production and release of cortisol as a heat generation process
B)Stimulation of the thyroid gland in order to increase cellular activity
C)Heat production through increased body mabolism
D)Energy generation through the release of epinephrine andnorepinephrine

Answer 24

Ans: C
Feedback:
An immediate response to low temperature is a heat-generating increase in metabolism. Cortisol is not involved in heat generation, and the thyroid is only capable of a longer-term effect on metabolic activity. Epinephrine and norepinephrine shift activity away from energy production and toward heat production.

Question 25

An agricultural worker is picking fruit on a day when the air temperature is106°F. Which of the following processes will most likely be occurring while he works?
A)Conduction of heat from the air will be heating his skin surface and raising his core temperature.
B)Blood volume at his skin surface will be increasing to dissipate heat.
C)His autonomic nervous system will be stimulating him to sweat.
D)Radiation from his skin surfaces will be dissipating heat into the environment.

Answer 25

Ans: B
Feedback:
In response to high temperatures, blood volume at the surface increases in order to dissipate heat. Heat exchange between his body and the air is radiation, not conducti on, and the sympathetic, not autonomic, nervous system will be in control of the sweating process. Because the air temperature exceeds his body temperature, he will not be able to lose heat in this way.

Question 26

A health educator is teaching a group of colleagues about the physiology of thermoregulation. Which of the following statements is most accurate?A)“Endogenous pyrogens induce host cells to produce exogenous pyrogens.”
B)“Prostaglandin E2(PGE2) exerts a direct fever-producing effect on the hypothalamus.”
C)“PGE2 induces Kupffer cells to initiate a fever response via hepatic sinusoids.”
D)“Arachidonic acid induces cytokines to act on the temperature regulation center .”

Answer 26

Ans: BFeedback:PGE2 is the protein that exerts control on the hypothalamus and induces fever. Exogenous pyrogens induce host cells to produce endogenous pyrogens, and Kupffer cells produce PGE2. Cytokines do not act directly in the hypothalamus

Question 27

A physician is noting the recent vital signs for several patients on an acute medical ward of a hospital. Which of the following hospital patients with noninfectious diagnoses would most likely have a fever?
A)A 71-year-old female with limited mobility, chronic obstructive pulmonary disease, and vascular dementia
B)A 33-year-old female with a postoperative deep vein thrombosis and pulmonary embolism
C)A 51-year-old obese male with hepatic encephalopathy secondary to alcohol abuse
D)A 71-year-old male with congestive heart failure and peripheral edema

Answer 27

Ans: B
Feedback:
Pulmonary emboli can produce a fever. The other diagnoses do not.

Question 28

A 54-year-old man presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after spending an afternoon building a deck on a very hot, humid day. The physician assessing the man is performing a differential diagnosis as part of her assessment. Which of the following findings would suggest fever rather than hyperthermia as a cause of the elevation in the man’s temperature?A)Moist skin
B)Dizziness
C)Shivering
D)Cognitive changes

Answer 28

Ans: C
Feedback:
Shivering is a response to a signal for increased heat production. It would only occur on a hot day if the set point for temperature regulation were increased, as in the case of fever but not hyperthermia. Moist skin, cognitive changes, and dizziness can occur with either fever or hyperthermia

Question 29

A nurse is providing care for a 44-year-old male client who is admitted with a diagnosis of fever of unknown origin (FUO). Which of the following characteristics of the client history is most likely to have a bearing on his current diagnosis?
A)The client is cachexic and an African American.
B)The client is HIV positive and homeless.
C)The client is malnourished, hypomagnesemic, and hypocalcemic.
D)The client is receiving intravenous normal saline with 20 mEq KCl.

Answer 29

Ans: B
Feedback:
FUO is associated with HIV. The other aspects of the client’s circumstances are not noted to correlate with FUO.

Question 30

In the hospital setting, one of the best ways to lower a hyperthermic patient’s fever would be to facilitate conduction of heat from the body by
A)providing frequent sponge baths with cool water.
B)taking all covers/clothing off and pouring alcohol on the skin.
C)placing him or her on a cooling mattress that circulates a coolant solution through the mattress.
D)placing IV solutions into the freezer for 30 minutes prior to hanging them.

Answer 30

Ans: C
Feedback:
Cooling mattress facilitates the conduction of heat from the body into the coolant solution that circulates through the mattress. Care must be taken so that the cooling method does not produce vasoconstriction and shivering. Sponge baths and alcohol solutions increase evaporative heat loss but may cool them too quickly. IV solut ionsshould not be placed in a freezer.

Question 31

A child aged 33 days is presented to the emergency department of a hospital by her parents following a 2-day fever. Her temperature is 38°C (100.4°F) tympanically. Which of the following diagnostic tests is most clearly indicated?
A)Electrolytes, blood urea nitrogen (BUN), and creatinine levels
B)Abdominal ultrasound
C)Computed tomography (CT) of the head
D)Urine for culture and sensitivity

Answer 31

Ans: D
Feedback:
Infants with a fever are at risk of urinary tract infections, which would be diagnose dthrough a urine test for culture and sensitivity. Electrolytes, BUN and creati nine, CT head, and abdominal ultrasound are not asclosely associated with differential diagnosisof the child’s fever.

Question 32

An 88-year-old resident of a long-term care home has been suffering from a 3-day onse tof increased shortness of breath and decreased oxygen saturation. At the hospita l, ananterior-posterior chest x-ray and sputum culture and sensitivity have confir med adiagnosis of bacterial pneumonia, yet the client’s tympanic temperature has not exceeded 37.3°C (99.2°F). The health care team would recognize that which of the following phenomena likely underlies this situation?
A)An older adult is often insensitive to exogenous pyrogens.
B)An older adult is sometimes incapable of vasodilation.
C)An older adult’s hypothalamus has diminished thermoregulatory ability.
D)Infections manifest by cognitive changes in older adults

Answer 32

Ans: C
Feedback:
The hypothalamus in older adults is often less capable of thermoregulation than inyounger clients. There are sometimes alterations in the release of endogenous pyroge nsand deficits in vasoconstriction. While infections do often manifest with cognit ivechanges in older adults, this does not explain why fever is precluded.

Question 33

A 14-year-old boy is participating in his school’s track meet; the outdoor temperature is99°F, and a teacher has found the boy sitting restless in the shade and disoriente d totime. The teacher notes that the student has dry skin in spite of the high temperature a ndthe fact that he has recently completed a running event. The teacher calls for the school nurse, who will recognize which of the following potential diagnoses and anticipated hospital treatments?A)Heat exhaustion, likely treated with rest, shelter from the sun, and salt tablets
B)Heat stroke, likely treated with submersion in cold water
C)Heat stroke, likely treated with rehydration by intravenous hypotonic solution
D)Heat exhaustion, likely treated with oral rehydration with cool water

Answer 33

Ans: B
Feedback:
Cognitive changes and lack of sweating are signs of heat stroke as opposed to hea texhaustion. A common treatment for heat stroke is immersion in cold water to rapidl ydecrease the core and shell temperature. Salt tablets, hypotonic IVrehydration, and ora lwater rehydration would not be appropriate treatments.

Question 34

About 30 minutes following the morning medication pass, the nurse’s aide informs the nurse that one of the patients on their team is complaining of “hot sweats.” The aide also states that his temperature is now 101.5°F. Knowing that some medications can cause hyperthermia, the nurse reviews his medications. From the following patient list, which patient is at high risk for developing an elevated temperature?
A) Patient with hypertension being treated with Prinivil (Lisonopril)
B)Suicidal patient who overdosed on his monoamine oxidase (MOA) inhibitor.
C)Postoperative patient receiving Oxycodone (OxyContin) for his pain.
D)Patient with C. difficile receiving Vancocin (Vancomycin) IV every 6 hours.

Answer 34

Ans: B
Feedback:
Overdoses of serotonin reuptake inhibitors or use in people taking MOA inhibitors cancause agitation, hyperactivity, and hyperthermia.

Question 35

A 20-year-old female has been brought to the emergency department from a rave pa rtywhere she collapsed on the dance floor. Her accompanying friends acknowledge that the woman took ecstasy early in the evening. Her heart rate is regular at 89 beats/mi nuteand temperature 39.8°C (103.6°F) orally. The emergency team would recognize that which of the following phenomena, related to the drug, is a likely contributor to the woman’s status?
A)Increased peripheral vasoconstriction
B)The direct pyrogenic effect of ecstasy
C)The initiation of an inappropriate immune response
D)Impaired temperature regulation by the hypothalamus

Answer 35

Ans: A
Feedback:
Amphetamines such as ecstasy can induce hyperthermia by increasing periphera lvasoconstriction. They are not associated with direct hypothalamic effect, pyrogenic effect, or an immune response.

Question 36

During surgery, the anesthesia personnel noticed the patient is having a steady rise in his end-tidal carbon dioxide level. At this time, the nurse anesthetist begins to assess the patient for malignant hyperthermia. The initial (priority) assessment for this disorder may include
A)hypotension.
B)acute renal failure.
C)skeletal muscle rigidity.
D)sudden cardiac arrest.

Answer 36

Ans: C
Feedback:
In addition to a steady rise in end-tidal carbon dioxide levels, an initial sign of thedisorder, when the condition occurs during anesthesia, is skeletal muscle rigidity

Question 37

In the ED, a homeless patient is brought in with severe hypothermia. The police officers also state that they found a “bottle of booze” on the sidewalk next to him. This puts the nurse on high alert since alcohol contributes to hypothermia by
A)interfering with the appetite center in the brain causing the person to not respond to hunger pains.
B)causing the person to have less fat on his body.
C)dulling the mental awareness that impairs judgment to seek shelter.
D)increasing his basal metabolic rate, so he will run out of ATP faster than expected.

Answer 37

Ans: C
Feedback:
Alcohol and sedative drugs dull mental awareness to cold and impair judgment to see kshelter or put on additional clothing. Alcohol also inhibits shivering. It does not interfe rewith the appetite center. Malnutrition causes the person to have less fat. Alcohol may initially increase pulse, but as the hypothermia continues, the pulse rate will lower.

Question 38

An 80-year-old woman is undergoing total hip replacement surgery as treatment for severe osteoarthritis. During the procedure, the patient’s core temperature falls to 31.6° C(88.9°F), necessitating interventions to address her hypothermia. The surgical team recognizes that there are likely multiple causes of patient’s hypothermia. Which of the following factors would the team be most justified in ruling out as a contributor?
A)The cold environment in most operating theaters
B)Decreased vasoconstriction as a result of anesthetic
C)Decreased temperature adaptation due to her unconscious state
D)Impaired thermoregulatory mechanisms due to anesthetic

Answer 38

Ans: C
Feedback:
Unconsciousness inand of itselfis not an identified contributor to surgical hypothermia .The cold environment, decreased vasoconstriction, and impaired thermore gulationresulting from an anesthetic are all potential contributors.

Question 39

A 38-year-old male client with mild hypothermia following a prolonged hike in the rain is brought to the hospital by ambulance. Which of the following sets of vital signs would be the most characteristic of the client's diagnosis?
A)BP178/102; RR 12; HR 58
B)BP 109/68; RR9;HR 130
C)BP 160/99; RR30; HR66
D)BP138/84; RR 28; HR111

Answer 39

Ans: D
Feedback:
Mild hypothermia is associated with accelerated HR, slightly increased BP, a ndhyperventilation; these parameters are best characterized by the vital signs referred in answer D.

Question 40

Following a cardiothoracic surgery, where controlled therapeutic hypothermia was utilized to decrease metabolic demands, the nurse responsible for recovering this patient should be assessing for which of the following potential complications to cold cardioplegia?A)Development of a first-degree AV block
B)Vasoconstriction resulting in weak pedal pulses, requiring the use of a Doppler
C)Frequent premature ventricular contractions (PVCs) on the telemetry monitor
D)Cyanosis in lower extremities with no blanching in the toes

Answer 40

Ans: C
Feedback:
Potential complications to cold cardioplegia include such signs and symptoms as ventricular dysrhythmias, decreased cerebral blood flow, and postoperative myocardial depression. First-degree AV block is common in patients with heart problems. Vasoconstriction of vessels is an expected effect of cold cardioplegia along with cold, bluish lower extremities.