CHAPTER 3: INFLAMMATION, THE INFLAMMATORY RESPONSE, AND FEVER
QUESTIONS AND ANSWERS 2022
A nurse's hand-off reports states that the patient has
... [Show More] pyrexia. The nurse plans care
for the patient with which of the following events?
a) Fever
b) Incontinence
c) Wound
d) Rash - ANS-Fever
When a patient is documented to have pyrexia, the nurse should plan care for a
patient with a fever.
A client asks why his temperature is always below 98.6°F. The nurse responds:
a) A person's highest point of core temperature is usually first thing in the morning.
b) The best way to bring your body temperature up to normal is to live in a warmer
climate.
c) Some people maintain a core body temperature of 41°C and that is normal for
them.
d) Normal core temperature varies between individuals within the range of 97.0°F to
99.5°F. - ANS-Normal core temperature varies between individuals within the range
of 97.0°F to 99.5°F.
Core temperature is normally maintained within a range of 36.0°C to 37.5°C (97.0°F
to 99.5°F).
-A core temperature greater than 41°C (105.8°F) or less than 34°C (93.2°F) usually
indicates that the body's thermoregulatory ability is impaired.
- Body heat is generated in the tissues of the body, transferred to the skin surface by
the blood, and then released into the environment surrounding the body.
-The thermoregulatory center regulates the temperature of the deep body tissues, or
"core" of the body, rather than the surface temperature.
-Internal core temperatures reach their highest point in late afternoon and evening
and their lowest point in the early morning hours.
Which of the following patients is most likely to have impairments to the wound
healing process? A patient with:
a) A diagnosis of multiple sclerosis and consequent impaired mobility.
b) Congenital heart defects and anemia.
c) Poorly controlled blood sugars with small blood vessel disease.
d) Chronic obstructive pulmonary disease. - ANS-Poorly controlled blood sugars
with small blood vessel disease.
Diabetes mellitus is strongly associated with impaired wound healing. The other
noted pathologies are less causative of deficiencies in the healing process.
A client has an increase in core body temperature. What assessment findings does
the nurse expect?
a) Flushed skin
b) Decreased skin temperature
c) Blue nail beds
d) Decreased urination - ANS-Flushed skin
The client with an increase in their core temperature will be accompanied by flushed,
warm skin as the body tries to lower the temperature.
-The other assessments do not correlate with increased core temperature.
A client presents with an oral temperature of 38.7°C and painful, swollen cervical
lymph nodes. Laboratory results indicate neutrophilia with a shift to the left. Which
diagnosis is most likely?
a) A severe bacterial infection
b) A localized fungal infection
c) A mild parasitic infection
d) A mild viral infection - ANS-A severe bacterial infection
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.
A client has presented to the emergency department after he twisted his ankle while
playing soccer. Which assessment findings are cardinal signs that the client is
experiencing inflammation? Select all that apply.
a) The ankle is bleeding
b) The ankle is warmer than the unaffected ankle
c) The client is experiencing pain
d) The ankle appears to be swollen
e) The client's ankle is visibly red - ANS-• The ankle is warmer than the unaffected
ankle
• The client is experiencing pain
• The ankle appears to be swollen
• The client's ankle is visibly red
The cardinal signs of inflammation are rubor (redness), tumour (swelling), calor
(heat), and dolor (pain).
-Bleeding is not among the cardinal signs.
A two-day postoperative patient's temperature was 98.5°F at 3:00 pm. At 6:00 pm,
the unlicensed assistant notifies the nurse that the patient's temperature is 102.0°F.
Which of the following actions should the nurse take?
a) Offer the client a cold drink
b) Notify the physican
c) Increase intravenous fluid rate
d) Document the temperature - ANS-Notify the physician
The nurse should contact the physician, as the increase in the patient's temperature
is outside of the normal range and/or the normal diurnal variation in temperature.
The nurse needs to assess a 1-year-old child for fever. Which approach will produce
the most accurate reading?
a) Rectal
b) Axillary
c) Oral
d) Forehead - ANS-Rectal
Measurement of core body temperature is important when evaluating fever. The
rectal route is considered the most accurate. In adults and older children, the oral
route is lower, but still accurate; however, in young children the oral route may be
unreliable.
-Forehead thermometers can predict trends, but are not as accurate as other routes.
-The axillary route requires up to 10 minutes for the temperature to register
appropriately.
A patient with a rising temperature is pale and has begun to shiver. The nurse
reports that the patient is in which of the following phases of fever development?
CONTINUES... [Show Less]