Concept 21: Inflammation My Nursing Test Banks

Concept 21: Inflammation

Test Bank

MULTIPLE CHOICE

1. A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following?

a.

The coating on these medications is irritating to my intestines.

b.

I need a more immediate response from my medications than can be obtained from enteric coated medications.

c.

Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue.

d.

I dont need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks.

ANS: C

Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.

REF: 223

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. The nurse should tell the patient that

a.

she should use ice only when the ankle hurts.

b.

ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days.

c.

she should wrap an ice pack around the injured ankle for the next 24 to 48 hours.

d.

ice is not recommended for use on the sprain because it would inhibit the inflammatory response.

ANS: B

Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

REF: 222 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

3. A patient is being treated with an antibiotic. The nurse explains to the patient that this medication is required for the reduction of inflammation at the injury site because this medication

a.

will decrease the pain at the site.

b.

helps to kill the infection causing the inflammation.

c.

inhibits cyclooxygenase.

d.

will reduce the patients fever.

ANS: B

Antimicrobials treat the underlying cause of the infection which leads to inflammation. Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

REF: 216

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patients wound. The nurse realizes that this fluid

a.

contains the materials used by the body in the initial inflammatory response.

b.

indicates that the patient has an infection at the site of the wound.

c.

is destroying healthy tissue.

d.

results from ineffective cleansing of the wound area.

ANS: A

Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaning done to the area of injury.

REF: 216-217

OBJ: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

5. The nurse reviews the patients complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates _____ inflammatory response.

a.

chronic

b.

resolved

c.

early stage acute

d.

late stage acute

ANS: C

Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response. Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative of resolved inflammation. Elevations in monocytes occur later in the inflammatory response.

REF: 217

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. The nurse plans to teach the patient to

a.

not eat with the other students.

b.

avoid sharing razors and other personal items.

c.

have his CBC checked monthly.

d.

disinfect showers and bathroom floors weekly after use.

ANS: B

Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause inflammation and infection. Not eating with the others in his college apartment wont relieve or prevent the spread of infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.

REF: 217 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation.

a.

Oral temperature 38.6 C/101.5 F

b.

Thick, green nasal discharge

c.

Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses

d.

WBC 20 109/L

e.

Patient reports, Im tired all the time. I havent felt like myself in days.

ANS: A, D, E

Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

REF: 221

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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