A nurse is assisting in explaining the pathophysiology of systemic inflammatory response syndrome (SIRS) to a group of newly licensed nurses. Which of the following statements by the nurse is accurate?

"Activation of the inflammatory cascade causes increased perfusion."

The major organ prone to injury during SIRS is the heart."

Spleen dysfunction causes blood clotting issues."

"A deregulated cytokine storm causes an inflammatory response."

Answer and Explanation

The Correct Answer is D

A. Activation of the inflammatory cascade in SIRS typically leads to decreased perfusion and tissue damage due to widespread inflammation and capillary leakage.

B. SIRS can affect multiple organs, but it is particularly known for impacting the lungs and kidneys rather than the heart.

C. While SIRS can involve coagulation issues, these are not specifically due to spleen dysfunction but rather to the widespread inflammatory response.

D. SIRS is driven by a deregulated cytokine storm, which leads to an excessive and uncontrolled inflammatory response, potentially resulting in multiple organ failure.

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Correct Answer is C

Explanation

A. Distended neck veins are typically associated with fluid overload, not dehydration.

B. An elevated blood pressure is not a common indicator of dehydration; dehydration often leads to hypotension.

C. An elevated urine specific gravity (greater than 1.030) indicates concentrated urine, which is a sign of dehydration as the body conserves water.

D. A bounding pulse is more indicative of fluid overload rather than dehydration, which often causes a weak, thready pulse.

A. The nurse disagrees with the nurse manager about inadequate staffing. B. The nurse discovers that client does not have advanced directives. C. A staff member has not arrived at the facility to work an assigned shift. D. A client tells the nurse that his dentures are missing.

Correct Answer is D

Explanation

A. Disagreements about staffing issues should be addressed through appropriate channels, but they do not typically require an incident report.

B. The absence of advanced directives is a concern that needs to be addressed, but it does not constitute an incident that requires reporting.

C. A staff member not arriving for their shift is a staffing issue but does not require an incident report unless it directly affects client care.

D. Missing dentures are considered a loss of personal property, which requires documentation through an incident report to ensure accountability and to initiate a search or compensation process.

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A nurse is assisting in explaining the pathophysiology of systemic inflammatory response syndrome (SIRS) to a group of newly licensed nurses. Which of the following statements by the nurse is accurate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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