The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis? Sepsis In severe bacterial infections (sepsis), large quantities of microorganisms in the blood result in the production and release of enormous quantities of inflammatory cytokines and development of what is referred to as systemic inflammatory response syndrome. Systemic inflammatory response syndrome results in generalized vasodilation, increased vascular permeability, intravascular fluid loss, myocardial depression, and fatal circulatory shock. During a lecture on inflammation, the physiology instructor discusses the major cellular components involved in the inflammation response. The instructor asks, "Which cells arrive early in great numbers?" Which student response is correct? Neutrophils Neutrophils are the primary early arrival cells and are signified by an elevated neutrophil count that includes mature (PMNs) and immature (bands) cell forms. Basophils respond later. Lymphocytes have a slower arrival and stay longer. The half-life of circulating monocytes is about a day, after which they begin to migrate to the site of injury and mature into larger macrophages, which have a longer half-life and greater phagocytic ability than do blood monocytes. A nursing student is cleaning a client's sacral pressure injury by vigorously scrubbing the wound bed to remove all of the beefy, red tissue that existed there. What type of tissue did the student most likely removed? Granulation tissue Granulation tissue is a glistening red, moist connective tissue that fills the injured area while necrotic debris is removed. Stem cells will not exist in a wound bed and necrotic tissue would not be bright red. The student has likely done the client a disservice by cleansing aggressively. A client sustained an injury 3 days ago. The nurse is assessing the status of the wound and anticipates the wound to be in which phase of healing? Proliferative Which condition is an example of wound healing by secondary intention? An infected burn of the arm A sutured surgical incision is an example of healing by primary intention. Larger wounds (e.g., burns and large surface wounds) that have a greater loss of tissue and contamination heal by secondary intention. Healing by secondary intention is slower than healing by primary intention and results in the formation of larger amounts of scar tissue. A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as a/an: increase in
circulating neutrophils. Leukocytosis, or the increase in white blood cells, is a frequent sign of an inflammatory response, especially those caused by bacterial infection. Leukocytosis occurs due to an increase in circulating neutrophils and eosinophils. Leukocytosis does not occur because of increased cell production, and blood supply is typically increased as part of the inflammatory process. A nurse is assessing a client
for the classic signs of acute inflammation. The nurse would assess the client for: Rubor, swelling, and pain The classic signs of inflammation are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). The remaining options are more characteristic of symptomatology resulting from circulatory dysfunction. When caring for a client during the proliferative phase of wound healing, the nurse teaches the client that which of these processes is taking place? Fibroblasts secrete collagen for wound healing. During the proliferative phase, fibroblasts synthesize and secrete collagen and other intercellular elements needed to fill the wound space. Fibroblasts also produce a family of growth factors that induce angiogenesis and endothelial cell proliferation and migration. The nurse is caring for a client with an accumulation of 2.5 cm of darkened tissue scar over the area of a 3-mm injury. How does the nurse correctly document this finding in the medical record? keloid Keloids are tumor-like masses caused by excess production of scar tissue. The tendency toward development of alkaloids seems to have a genetic basis. The nurse is caring for a client who has experienced hypovolemic shock secondary to penetrating multiple trauma. When caring for the client postoperatively, which of these factors does the nurse recognize places the client at risk for poor wound healing? Tissue hypoxia Impaired wound healing may occur due to poor blood flow (e.g., swelling) or preexisting health problems. In situations of trauma, a decrease in blood volume may cause a reduction in blood flow to injured tissues. Hyperbaric oxygen is a treatment that delivers 96% to 100% oxygen at greater than twice the normal atmospheric pressure at sea level to improve wound healing. Keloids are masses produced from excess scar tissue; scar tissue formation is the final phase of wound healing. The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as: Exudate containing white blood cells, protein, and tissue debris A purulent or suppurative exudate contains pus, which is composed of degraded white blood cells, proteins, and tissue debris. Fibrinous exudates contain large amounts of fibrinogen. Serous exudates are watery fluids low in protein. Hemorrhagic exudates occur when there is severe tissue injury that causes damage to blood vessels or when there is significant leakage of red cells The nurse is assessing the wound of a postoperative client. The client has a 6-inch abdominal wound that is well approximated and closed with surgical suture. The wound does not display any redness or drainage. The nurse would document the healing process as: Primary intention A sutured surgical incision is an example of healing by primary intention. Secondary intention is slower than healing by primary intention and results in the formation of larger amounts of scar tissue. Tertiary intention is a wound that is open and needs to be closed when granulation tissue forms. There is not a progressive intention. A client who had an implantable cardioverter-defibrillator (ICD) returns the next week with a fever, chills, and elevated WBC. The physician suspects the wound is infected. If this wound does not respond to antibiotic therapy, the nurse can anticipate the client will undergo: Removal of device Wound infections are of special concern in persons with implantation of foreign bodies such as orthopedic devices (e.g., pins, stabilization devices), cardiac pacemakers, and shunt catheters. These infections are difficult to treat and may require removal of the device. All wounds are considered contaminated at the time they occur. Usually, the natural defenses in our bodies can deal with the invading microorganisms; however, there are times when a wound is badly contaminated and host defenses are overwhelmed. What happens to the healing process when host defenses are overwhelmed by infectious agents? The formation of granulation tissue is
impaired. Infection impairs all dimensions of wound healing. It prolongs the inflammatory phase, impairs the formation of granulation tissue, and inhibits proliferation of fibroblasts and deposition of collagen fibers. All wounds are contaminated at the time of injury. Although body defenses can handle the invasion of microorganisms at the time of wounding, badly contaminated wounds can overwhelm host defenses. Trauma and existing impairment of host defenses can also contribute to the development of wound infections. A class of student nurses is hearing a lecture on wound healing. The professor explains about primary and secondary healing. What are the phases of wound healing? Select all that apply. Proliferative phase Wound healing is commonly divided into three phases: (a) the inflammatory phase, (b) the proliferative phase, and (c) the maturational or remodeling phase. There is no activation or nutritional phase in wound healing. Which responsibility of the extracellular matrix (ECM) is most accurate? The ECM provides the scaffolding for tissue renewal. The ECM provides the scaffolding for tissue renewal. Although the cells in many tissues are capable of regeneration, injury does not always result in restoration of normal structure unless the ECM is intact. Some of the proteases, such as the collagenases, are highly specific, cleaving particular proteins at a small number of sites. This allows for the structural integrity of the ECM to be retained while healing occurs. Following a severe automobile accident, a client is scheduled to have surgery to either repair or remove his spleen, pancreas, and stomach. The client wants the organs repaired and not removed if at all possible. However, the nursing staff understands that extensive regeneration in parenchymal organs can only occur if: the residual tissue is structurally and functionally intact. Regeneration can occur in parenchymal organs with stable cell populations but, with the exception of the liver, is usually a limited process. It should be pointed out that extensive regeneration can occur only if the residual tissue is structurally and functionally intact. If the tissue is damaged by infection or inflammation, regeneration is incomplete and accomplished by replacement with scar tissue. A client presents with an oral temperature of 101.7°F (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 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. Which child has the highest risk of experiencing a wound complication? Child recently been diagnosed with type 2 diabetes Children with certain comorbidities such as diabetes and malabsorption problems will be at higher risk of wound complications. Of course, secondary infections can occur after antibiotic courses, but this is not the primary cause of wound complications. A student arrives at the health clinic anxious and afraid. The student found an enlarged lymph node in the groin area that is extremely painful to touch and "knows" it is cancer. What information should the health care provider relay to this student about lymphadenitis? Not all swollen lymph nodes are due to cancer. It could be caused by an infection in the genital region. The nurse is caring for a client with a chronic wound. The most important
intervention for the nurse to include in the plan of care would be: Vitamin C and zinc supplements Vitamins play an essential role in the healing process. Vitamin C is needed for collagen synthesis. Zinc has been found to aid in re-epithelialization. Vitamin C and zinc supplements are often ordered for clients with chronic wounds to promote wound healing. Steroid therapy would decrease wound healing. A diet high in proteins and carbohydrates would be ordered to promote wound healing. Which client is at greatest risk for decreased wound healing? An adult client with type 1 diabetes and an infection in the foot The nurse is selecting a dressing for a vascular wound that has a dry wound surface. The most appropriate dressing for this wound is one that: adds moisture to wound bed. The most appropriate dressing for this wound is one that adds moisture to the wound bed, as epithelial cell migration requires a moist vascular wound bed. The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess? Edema Cardinal signs of inflammation include rubor (redness), tumor (swelling or edema), calor (heat), dolor (pain) and functio laesa (loss of function). Tissue necrosis occurs with chronic inflammation. The nurse is caring for an obese client who has had abdominal surgery. The medical record states the wound has developed a dehiscence. Which finding does the nurse anticipate observing when changing the dressing? Wound edges are 1.5 inches apart. Mechanical factors such as increased local pressure or torsion can cause wounds to pull apart, or dehisce. The rehabilitation nurse is caring for a client who is recovering from a cerebrovascular accident (CVA) with hemiplegia. The family asks the nurse if the paralysis will be permanent. Upon which of these physiologic rationales should the nurse base the response? It is likely that paralysis is permanent, as nerve cells do not normally regenerate. Labile cells continue to divide and replicate throughout life, replacing cells that are continually being destroyed. Stable cells are those that normally stop dividing when growth ceases; however, they are capable of regeneration when confronted with an appropriate stimulus. Permanent or fixed cells, including nerve cells, skeletal muscle cells, and cardiac muscle cells cannot undergo mitotic division. Once destroyed, they are replaced with fibrous scar tissue. Exudate into a wound area is generally short-lived; however, once damaged, the nerve cells cannot regenerate. The nurse is assessing a client with diabetes and notes an area on the client's right foot as inflamed, necrotic, and eroded. The client states he accidentally slammed his foot in a door 2 weeks ago. The nurse would document this finding as a(n): Ulceration Ulceration refers to a site of inflammation where an epithelial surface (e.g., skin or gastrointestinal epithelium) has become necrotic and eroded, often with associated subepithelial inflammation. Ulceration may occur as the result of traumatic injury to the epithelial surface (e.g., peptic ulcer) or because of vascular compromise (e.g., foot ulcers associated with diabetes).The other options do not present these manifestations Following surgery for appendicitis, a teenaged client notes four small "stab" wounds on the abdomen. The client is obviously worried about body appearance. The nurse explains, "Your body will heal quickly and tissue repair will allow for regeneration of any cells needed." The client asks, "What does regeneration mean?" The nurse responds that tissue repair by regeneration means: "Any injured cells are replaced with cells of the same type. Therefore, after healing, the wound will look like your surrounding
skin." Tissue repair can take the form of regeneration, in which injured cells are replaced with cells of the same type, sometimes leaving no residual trace of previous injury. Replacement by connective (fibrous) tissue will lead to scar formation. After many years of cigarette smoking, a client is admitted to have a "mass" removed from the lung. When explaining the surgery and recovery, the physician notes that the client is likely to have a good amount of fibrosis develop at the surgical area. After the physician leaves the room, the client asks the nurse what was meant by "fibrosis" in the lung. The nurse bases the response on the fact that tissue repair can: result in replacement tissue in the form of connective (fibrous) tissue, which leads to scar formation or fibrosis of the lung. Tissue repair can take the form of replacement by connective (fibrous) tissue, which leads to scar formation or fibrosis in organs such as the liver or lung. Regeneration of tissue results with injured cells being replaced with cells of the same type. Although age does play a role in tissue healing, it is not the only factor that can result in scar formation. An oncology client is about to begin chemotherapy. During the education, the nurse mentions that continuously dividing cells will be most affected by the
chemotherapy. The client asks, "What are continuously dividing cells?" The nurse responds, "These are cells that continue to divide and replicate like: cells on the surface of your skin." Continuously dividing or labile tissues are those in which the cells continue to divide and replicate throughout life, replacing cells that are continually being destroyed. They include the surface epithelial cells of the skin, oral cavity, vagina, and cervix; the columnar epithelium of the gastrointestinal tract, uterus, and fallopian tubes; the transitional epithelium of the urinary tract; and bone marrow cells. Neurons lose their ability to proliferate once development of the nervous system is complete. Heart muscle cells were believed to not regenerate; however, recent findings suggest that about half of your heart's muscle cells are normally replaced over a lifetime. However, it is a slow process and these cells are not continuously dividing. While educating a group of individuals about to undergo knee surgery, the nurse stresses the importance of eating a well-balanced diet, especially high in vitamins. Which vitamin promotes collagen synthesis to facilitate the wound to the knee to heal properly? Vitamin C Vitamin C is needed for collagen synthesis. In vitamin C deficiency, improper sequencing of amino acids occurs, proper linking of amino acids does not take place, the by-products of collagen synthesis are not removed from the cell, new wounds do not heal properly, and old wounds may pull apart. Vitamin A functions in stimulating and supporting epithelialization, capillary formation, and collagen synthesis. Vitamin K plays an indirect role in wound healing by preventing bleeding disorders that contribute to hematoma formation and subsequent infection. 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. The client's ankle is visibly red The cardinal signs of inflammation are rubor (redness), tumor (swelling), calor (heat), and dolor (pain). Bleeding is not among the cardinal signs.
In the vascular phase of acute inflammation, initial vasoconstriction is followed rapidly by which assessment finding? Heat and redness The nurse is caring for a client whose temperature is increasing. Which other vital sign/body response will the nurse monitor for an increase? Heart rate Critical to the analysis of a fever pattern is the relation of heart rate to the level of temperature elevation. The features of a systemic response includes fever, hypotension, increased heart rate, anorexia, release of neutrophils into circulation, and increased levels of corticosteroid hormones. The remaining options are not as closely related to fever as heart rate. In contrast to acute inflammation, chronic inflammation is characterized by which physiologic phenomena? Infiltration of lymphocytes and macrophages Chronic inflammation requires lymphocytes and macrophages to remain in large numbers for the high use of immune cells. Chronic inflammation is associated with fibroblast proliferation instead of exudations. A "shift to the left" is characteristic of acute inflammation with a high neutrophil count. Inflammation, with continued cell injury, is a source of metabolic and respiratory (if the lungs are the site of inflammation) acidosis. The wound care nurse
is teaching a group of nurses about wound healing and, specifically, delays in wound healing. Which situations that interfere with wound healing, and could cause a delay in healing, should the nurse include in the discussion? Select all that apply. Hyperglycemia Clients with diabetes and hyperglycemia do not respond well to traditional methods of wound treatment because of their high blood glucose levels. Evidence shows delayed wound healing and complications such as prolonged infections in people with diabetes delay wound healing. Gaping wounds tend to heal more slowly because it is often impossible to effect wound closure with this type of wound. Successful wound healing depends in part on adequate stores of proteins, carbohydrates, fats, vitamins (C), and minerals. Children's wounds tend to heal well. When caring for a postoperative client, in order to promote wound healing, which of these nutrients does the nurse encourage the client to consume? Vitamin C Vitamins are essential cofactors for the daily functions of the body; vitamins A and C play an essential role in the healing process. Vitamin C is needed for collagen synthesis. Vitamin K plays an indirect role in wound healing by preventing bleeding disorders that contribute to hematoma formation and subsequent infection. Proteins, fats, carbohydrates and microminerals such as zinc are required for wound healing as well. When caring for a client who has developed bacterial pneumonia, the nurse assesses for which of these abnormalities that supports presence of infection? Leukocytosis Bacterial infections produce a relatively selective increase in neutrophils (neutrophilia), a type of white blood cell, whereas parasitic and allergic responses induce eosinophilia. Viral infections tend to produce a decrease in neutrophils (neutropenia) and an increase in lymphocytes (lymphocytosis). Thrombocytes or platelets assist in blood clotting. Neutropenia refers to a decrease in neutrophils, a type of WBCs, during times of immunosuppression or immunocompromise. The nurse is providing discharge instructions for a postoperative client. The nurse determines the teaching is effective when the client verbalizes which statement about wound healing? "I will regain almost full-tensile strength of an unwounded skin at the end of 3 months." At the end of the first week, wound strength is approximately 10%. It increases rapidly over the next 4 weeks and then slows, reaching a plateau of approximately 70% to 80% of the tensile strength of unwounded skin at the end of 3 months. Restrictions are necessary until strength is established. An infant was born with facial nerve paralysis that occurred with delivery. As the infant ages, it becomes apparent that the facial muscles affected by the nerve damage are not moving. Seeking surgical repair, the family asks why the damage to the child's face is not being repaired by the body. The health care provider states that neurons (connected to the facial muscles) are highly specialized cells that: lose their ability to proliferate once development of
the nervous system is complete. Neurons, which are highly specialized cells, lose their ability to proliferate once development of the nervous system is complete. In constant renewing cell populations, like the GI tract, the more specialized cells are unable to divide and rely on parent cells of the same lineage. Growth factors aide in tissue repair, not repair of neurons. What function does hyaluronic acid (a component of the extracellular matrix) perform in the body? Lubricates joints and serves as a supportive structure in the extracellular space throughout the body. Following an injury, the client's health care provider states the wound is healing well. The client asks the nurse, "If my wound is healing so fine, why is it still swollen?" The nurse's response is based on the principle that angiogenesis (which is occurring in the wound) can result in blood vessels being leaky due to which factors? Select all that apply. the residual tissue is structurally and functionally intact. Regeneration can occur in parenchymal organs with stable cell populations but, with the exception of the liver, is usually a limited process. It should be pointed out that extensive regeneration can occur only if the residual tissue is structurally and functionally intact. If the tissue is damaged by infection or inflammation, regeneration is incomplete and accomplished by replacement with scar tissue. A client with COPD controlled with long-term corticosteroids has developed an infection following bowel surgery. The nurse anticipated this complication since steroids: impair
the phagocytic property of leukocytes. The therapeutic administration of corticosteroid drugs decreases the inflammatory process and may delay the healing process. These hormones decrease capillary permeability during the early stages of inflammation, impair the phagocytic property of the leukocytes, and inhibit fibroblast proliferation and function. Steroid side effects usually cause hyperglycemia, muscle wasting, and hypertension. A
continuing education nurse in a long-term care facility is discussing wound healing in older adult clients. Because older adult clients are more likely to have comorbidities like problems with mobility, diabetes, or vascular problems, the nurse should assess the clients for which problems? Select all that apply. Pressure wounds on buttocks Older adults are more vulnerable to chronic wounds—chiefly pressure, diabetic, and ischemic ulcers—than younger persons, and these wounds heal more slowly. However, these wounds are more likely due to other disorders (e.g., immobility, diabetes mellitus, or vascular disease) rather than aging.
A nurse educator is describing the way that cells involved in the inflammatory response find their way to the site of injury. Which description best reflects this physiologic mechanism? "The process of chemotaxis is the process where cells wander through the tissue guided by secreted chemoattractants." Chemotaxis is the dynamic and energy-directed process of directed cell migration. Once leukocytes exit the capillary, they wander through the tissue guided by a gradient of secreted chemoattractant, bacterial and cellular debris, and protein fragments generated from activation of the complement system. Phagocytosis is the engulfment of foreign or infective material. Margination is the first step of the cellular stage and is a separate process from chemotaxis, which is the third step in the cellular response. Tissues do not store inflammatory cells. The nurse notes the client has developed a systemic response of
inflammation based on assessment findings. Which clinical manifestations support this diagnosis? Select all that apply. Temperature of 100.9°F (38.3°C) Manifestations of the acute-phase response include fever, anorexia, somnolence, and malaise. One would expect to see increased (not decreased) capillary permeability with acute inflammatory response. Throbbing headache is not an acute response. |
Which physiologic change occurs during the delayed phase of inflammation Quizlet
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