Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis.

Select the 3 findings consistent with a therapeutic response to interventions.

Serum blood glucose 185 mg/dL (10.2 mmol/L)

Temperature 98.8° F (37.1° C)

White blood cell count 11.2 x 103/μL (11.2 x 109/L)

Capillary refill greater than 3 seconds bilateral lower extremities

Bilateral lower extremities skin warm, dry, and pink

Pain 2 on a 0 to 10 pain scale, bilateral lower legs described as neuropathic

Answer and Explanation

Correct Answer : B,E,F

A. Serum blood glucose 185 mg/dL (10.2 mmol/L) (Incorrect): Although lower than the previous reading, it is still elevated, which can impair healing and increase the risk of infection recurrence.
B. Temperature 98.8°F (37.1°C) (Therapeutic Response): A return to a normal temperature indicates resolution of systemic infection. Fever is a sign of active infection, so its absence suggests improvement.
C. White blood cell count 11.2 x 10³/μL (11.2 x 10⁹/L) (Incorrect): This is slightly elevated, which may indicate residual inflammation or infection. A further decrease would be expected for full resolution.
D. Capillary refill greater than 3 seconds bilateral lower extremities (Incorrect): Delayed capillary refill suggests impaired circulation, which is not an indicator of a fully therapeutic response.
E. Bilateral lower extremities skin warm, dry, and pink (Therapeutic Response): Improved skin condition suggests reduced inflammation, better circulation, and healing of the cellulitis-affected area.
F. Pain 2 on a 0 to 10 pain scale, bilateral lower legs described as neuropathic (Therapeutic Response): Pain related to cellulitis typically improves with treatment. If the remaining pain is neuropathic, it suggests resolution of the acute infection.

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Correct Answer is A

Explanation

A. Increase in monocytes and macrophages. Monocytes and macrophages are key immune cells involved in the inflammatory response. Monocytes migrate to the affected tissue, where they differentiate into macrophages and help clear pathogens, dead cells, and debris. Their presence indicates an ongoing or chronic inflammatory process.
B. Predominance of megakaryocytes. Megakaryocytes are large bone marrow cells responsible for platelet production. They are not involved in inflammation and are typically found in the bone marrow, not in inflamed tissues.
C. Presence of fibroblasts and collagen. Fibroblasts and collagen are associated with tissue repair and scar formation rather than active inflammation. Their presence suggests healing and fibrosis rather than an acute inflammatory response.
D. Prevalence of dead neutrophils. Dead neutrophils are a hallmark of pus formation (suppuration) in bacterial infections but do not necessarily indicate ongoing inflammation. Neutrophils are the first responders in acute inflammation, but their presence alone does not define an inflammatory process—the presence of active immune cells like macrophages is more indicative.

A. Activation of exocytosis. B. Vasoconstriction. C. Decreased histamine production. D. Increased vascular permeability.

Correct Answer is D

Explanation

A. Activation of exocytosis. Exocytosis is a cellular process used for releasing substances such as neurotransmitters or hormones, but it is not the primary response to inflammation. The immune response involves chemical mediators like histamine, prostaglandins, and cytokines, which increase vascular permeability.
B. Vasoconstriction. Vasodilation, not vasoconstriction, is a hallmark of inflammation. Initially, there may be a brief period of vasoconstriction, but the primary response is vasodilation, which increases blood flow to the inflamed area.
C. Decreased histamine production. Histamine production increases during inflammation, leading to vasodilation and increased vascular permeability. This allows immune cells to travel to the site of injury or infection.
D. Increased vascular permeability. The inflammatory response involves increased vascular permeability, allowing immune cells, proteins, and fluid to move from the bloodstream into tissues to fight infection and promote healing. This process leads to swelling (edema), redness, and warmth, which are classic signs of inflammation.

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Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis.

Select the 3 findings consistent with a therapeutic response to interventions.