Inflammation Flashcards
Epidemiology of Clostridium difficile
Newborns & children in the first years of life have the highest rate of colonization, The risk of colonization increases steadily each day during hospitalization due to the daily risk of exposure to C difficile spores in a healthcare setting, people 85 years and older are 2x more likely to become infected with C difficile than people aged 65 to 84 years, the mortality attributable to C difficile is low when compared to that associated with MRSA & VRE; C difficile infection spreads mainly from the use of antimicrobials, particularly clindamycin, cephalosporins, & fluoroquinolones.
Assessment findings: Hypovolemia
Severe thirst, dry mucous membranes, concentrated urine output, oliguria
Assessment findings: Hypervolemia [fluid volume excess]
Edema (excess fluid outside the vascular space, in the tissues)
Priority actions with a positive Chvostek’s sign
Assess lung sounds [hypocalcemia can also cause wheezing & bronchospasms], Request a soft diet [hypocalcemia can cause difficulty swallowing], Evaluate the phosphorus level [calcium & phosphorus are inversely related], Monitor for cardiac dysrhythmias [cardiac effects of hypocalcemia lengthening of the QT interval which can predispose the client to ventricular dysrhythmias
Chvostek’s sign is a result of
Existing nerve hyperexcitability (tetany) seein in hypocalcemia
The student nurse learns that the most important function of inflammation and immunity is which purpose?
a. Destroying bacteria before damage occurs
b. Preventing any entry of foreign material
c. Providing protection against invading organisms
d. Regulating the process of self-tolerance
ANS: C
The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.
A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best?
a. Assess the client for more specific signs.
b. Conclude that an infection is not present.
c. Document findings and continue to monitor.
d. Request that the provider order blood cultures.
ANS: A
Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.
A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important?
a. Avoid large crowds and people who are ill.
b. Check over-the-counter meds for acetaminophen.
c. Take this medicine exactly as prescribed.
d. You have a higher risk of developing cancer.
ANS: A
Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf)
A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
a. Assessing vaccination records for booster shot needs
b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes
ANS: A
Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.
A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
ANS: B
During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.
A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils
ANS: A
The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.
The nurse understands that which type of immunity is the longest acting?
a. Artificial active
b. Inflammatory
c. Natural active
d. Natural passive
ANS: C
Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. Inflammatory is not a type of immunity.
The nurse working with clients who have autoimmune diseases understands that what component of cell- mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T cells
c. Natural killer cells
d. Suppressor T cells
ANS: D
Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.
A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
a. Dialysis
b. High-dose steroid administration
c. Monoclonal antibody therapy
d. Plasmapheresis
ANS: A
Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.
A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?
a. Blood urea nitrogen (BUN) of 18 mg/dL
b. Cloudy, foul-smelling urine
c. Creatinine of 3.9 mg/dL
d. Urine output of 340 mL/8 hr
ANS: C
A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.
