A nurse working in a burn unit cares for clients with complicated body system responses. Which response describes the body's initial reaction to a severe burn injury?
Anaphylactic.
Noncompensatory.
Inflammatory.
Cholinergic.
The Correct Answer is C
A. Anaphylactic. Anaphylactic reactions are caused by severe allergic responses, leading to histamine release, vasodilation, and bronchoconstriction. While burns trigger an immune response, it is an inflammatory reaction rather than an allergic one.
B. Noncompensatory. The body's response to burns is compensatory, not noncompensatory. The body immediately reacts by activating the inflammatory and stress responses to maintain perfusion and initiate healing.
C. Inflammatory. A severe burn triggers an immediate and massive inflammatory response, causing capillary leakage, fluid shifts (burn shock), and immune activation. This leads to edema, hypovolemia, and increased risk of infection. The inflammatory response also activates cytokines and white blood cells to begin tissue repair.
D. Cholinergic. The cholinergic response is related to the parasympathetic nervous system, which controls rest-and-digest functions. Severe burns primarily activate the sympathetic nervous system (fight-or-flight), leading to vasoconstriction, tachycardia, and increased metabolic demands.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}
Explanation
The nurse recognizes that a diagnosis of cellulitis can be explained by assessment findings of red, warm, swollen lower left leg and a small coach (likely wound or abrasion) above the affected area.
Rationale:
Cellulitis is a bacterial skin infection that presents with localized redness, warmth, swelling, and pain.
Red, warm, swollen lower left leg indicates inflammation and infection, which are key signs of cellulitis.
A small coach (likely wound or abrasion) above the affected area suggests a potential entry point for bacteria, increasing the risk of infection.
The client's history of generalized muscle aches and not feeling well suggests systemic involvement, which is common in infections.
Correct Answer is A
Explanation
A. Staphylococcus aureus abscess around a hair follicle. A furuncle, or boil, is a deep infection of a hair follicle caused by Staphylococcus aureus. It presents as a painful, pus-filled nodule due to bacterial invasion and inflammation. Poor hygiene, friction, or immune suppression can increase susceptibility.
B. Insect or spider bite that becomes infected. While insect bites can introduce bacteria into the skin, they do not directly cause furuncles. Secondary infection may occur, but furuncles specifically arise from infected hair follicles, not bites.
C. Sexual contact with an infected partner. Furuncles are not sexually transmitted infections. While skin-to-skin contact can spread Staphylococcus aureus, furuncles are not a direct result of sexual activity.
D. Inadequate blood supply to the area. Poor circulation can impair wound healing and increase infection risk, but furuncles result from bacterial infection of a hair follicle rather than ischemia.
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