A nurse is teaching a class about the steps of the inflammatory response. The nurse should include that which of the following is the first step in the inflammatory response?

Release of inflammatory markers, such as C-reactive protein

Recognition of harmful stimuli by pattern receptors on cell surfaces

Inflammatory cells are activated

Inflammatory pathways are triggered

Answer and Explanation

The Correct Answer is B

A. Release of inflammatory markers, such as C-reactive protein. C-reactive protein (CRP) is produced by the liver in response to inflammation, but its release occurs later in the inflammatory process, not as the initial step.

B. Recognition of harmful stimuli by pattern receptors on cell surfaces. The inflammatory response begins when pattern recognition receptors (PRRs) on immune cells, such as macrophages and dendritic cells, detect harmful stimuli like pathogens or tissue damage. This triggers a cascade of immune responses.

C. Inflammatory cells are activated. Once harmful stimuli are recognized, immune cells like neutrophils and macrophages become activated to eliminate the threat. However, cell activation occurs after the initial recognition step.

D. Inflammatory pathways are triggered. Inflammatory signaling pathways, such as the NF-κB and MAPK pathways, are activated after harmful stimuli are detected. These pathways regulate the production of cytokines and other inflammatory mediators.

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Correct Answer is A

Explanation

A. Focus charting. Focus charting uses the DAR (Data, Action, Response) format to document client care. It emphasizes patient-centered concerns, such as symptoms, behaviors, or nursing diagnoses. This method allows for structured yet flexible documentation of important observations and interventions.

B. Problem-oriented medical record (POMR). POMR organizes documentation around specific health problems, using components like the database, problem list, care plan, and progress notes. It does not specifically follow the DAR format.

C. SOAP documentation. SOAP stands for Subjective, Objective, Assessment, and Plan and is used for problem-focused documentation. It differs from DAR, as it emphasizes a structured approach to analyzing and addressing patient problems.

D. PIE model. The PIE model (Problem, Intervention, Evaluation) focuses on nursing diagnoses and interventions rather than the DAR method of focus charting. It provides a problem-oriented approach but does not use the same structure as DAR documentation.

A. Decreased peripheral pulses B. Dilated pupils C. Respiratory rate 10/min D. Heart rate 108/min

Correct Answer is D

Explanation

A. Decreased peripheral pulses. Fever leads to vasodilation and increased cardiac output, which generally enhances peripheral blood flow. As a result, peripheral pulses are more likely to be strong and bounding rather than decreased.

B. Dilated pupils. Pupil dilation is associated with sympathetic nervous system activation, often due to stress, fear, or certain medications. Fever alone does not typically cause pupil dilation, making this an unlikely expected finding.

C. Respiratory rate 10/min. Fever usually increases metabolic demand, leading to a higher respiratory rate (tachypnea) rather than a lower one. A respiratory rate of 10 breaths per minute would be considered bradypnea, which is not a typical response to fever.

D. Heart rate 108/min. Fever stimulates the sympathetic nervous system, increasing heart rate (tachycardia) to meet the body’s higher metabolic and oxygen demands. A heart rate of 108/min is expected in response to a fever of 39°C (102.2°F).

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A nurse is teaching a class about the steps of the inflammatory response. The nurse should include that which of the following is the first step in the inflammatory response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing with another nurse a method of documentation that includes data, action, and response (DAR) when charting client care. Which of the following methods of documentation is the nurse referring to?

Correct Answer is A

Explanation

A nurse is assessing a client who has an oral temperature of 39° C (102.2° F). Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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