The nurse is caring for a client who experienced multiple invasive trauma from a motor vehicle collision and has developed systemic inflammatory response syndrome (SIRS). Which pathophysiological process is most likely associated with the development of SIRS in this client?

Multiple organ dysfunction.

Acute kidney injury.

Intestinal obstruction.

Sepsis.

Answer and Explanation

The Correct Answer is A

A) Multiple organ dysfunction:

Correct. Systemic inflammatory response syndrome (SIRS) is a widespread inflammatory response to a variety of severe clinical insults, including trauma, infection, burns, or other sources of tissue injury. In the context of trauma from a motor vehicle collision, the body may mount a systemic inflammatory response involving multiple organ systems. This can progress to multiple organ dysfunction syndrome (MODS), where there is progressive dysfunction of two or more organ systems.

B) Acute kidney injury:

Acute kidney injury (AKI) can certainly occur in the context of severe trauma and systemic inflammation, such as in SIRS. However, AKI is a specific manifestation rather than the overarching pathophysiological process associated with the development of SIRS.

C) Intestinal obstruction:

Intestinal obstruction is a mechanical obstruction of the intestines and is not typically associated with the development of SIRS unless there is associated ischemia or perforation leading to systemic inflammation.

D) Sepsis:

Sepsis is a severe infection that has spread throughout the body and triggers a systemic inflammatory response. While sepsis can lead to SIRS, it is not the only cause. In this scenario, trauma from a motor vehicle collision is the primary cause of the systemic inflammatory response, rather than infection.

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Correct Answer is B

Explanation

The clinical manifestations described in the scenario, including lethargy, difficulty talking, hypertension (blood pressure of 146/122 mm Hg), and elevated urine specific gravity (1.055), are indicative of Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Here's a breakdown of the rationale:

A) Hyposecretion of Antidiuretic Hormone (ADH):

Hyposecretion of ADH would result in decreased levels of ADH, leading to increased urine output (polyuria) and low urine specific gravity. This condition is known as diabetes insipidus, characterized by excessive thirst and dilute urine. The elevated urine specific gravity in the scenario is inconsistent with diabetes insipidus. Therefore, this option is incorrect.

B) Syndrome of Inappropriate Antidiuretic Hormone (SIADH):

Correct. SIADH is a condition characterized by excessive release of antidiuretic hormone (ADH) from the posterior pituitary gland, leading to water retention, dilutional hyponatremia, and concentrated urine. The elevated urine specific gravity (1.055) in the scenario indicates concentrated urine, consistent with SIADH. Additionally, lethargy and difficulty talking are common neurological manifestations of hyponatremia, which can occur as a result of water retention in SIADH. The client's hypertension is likely a compensatory response to hyponatremia-induced cerebral edema. Therefore, SIADH is the most likely diagnosis in this context.

C) Hypopituitarism:

Hypopituitarism refers to deficient production of one or more pituitary hormones, which can lead to a variety of endocrine abnormalities depending on which hormones are affected. While it is possible for hypopituitarism to cause hyponatremia, the other clinical manifestations described in the scenario are not typically associated with this condition. Additionally, the elevated urine specific gravity is not consistent with hypopituitarism-induced hyponatremia. Therefore, this option is less likely.

D) Septic shock:

Septic shock is a life-threatening condition characterized by severe hypotension and tissue hypoperfusion due to systemic infection. While septic shock can cause altered mental status, hypotension (not hypertension), and oliguria (not concentrated urine), it is not typically associated with elevated urine specific gravity. Therefore, septic shock is not the most likely diagnosis in this context.

A. Lipase. B. Myoglobinuria. C. White blood count (WBC). D. Bilirubin.

Correct Answer is A

Explanation

A) Lipase:

Correct. Lipase is an enzyme produced by the pancreas that aids in the digestion of fats. Elevated levels of lipase in the blood can indicate pancreatic damage or inflammation, such as that which may occur due to trauma like a gunshot wound to the abdomen. Pancreatic injury can lead to leakage of enzymes into the bloodstream, resulting in elevated serum lipase levels. Monitoring lipase levels helps assess pancreatic function and detect injury or disease.

B) Myoglobinuria:

Myoglobinuria refers to the presence of myoglobin, a protein found in muscle cells, in the urine. It is often associated with muscle injury or breakdown, such as rhabdomyolysis. While abdominal trauma may result in muscle injury, myoglobinuria is not specific to pancreatic damage and is more indicative of muscle-related injury or conditions.

C) White blood count (WBC):

Elevated white blood cell count (WBC), or leukocytosis, is a non-specific marker of inflammation or infection. While it may occur in response to tissue injury, including pancreatic injury, it is not specific to pancreatic damage and can be elevated due to various other factors, such as surgical stress, infection, or inflammation.

D) Bilirubin:

Bilirubin is a pigment produced during the breakdown of red blood cells and is excreted by the liver. Elevated levels of bilirubin may indicate liver dysfunction or obstruction of the bile ducts, but they are not specific to pancreatic damage. While pancreatic injury can lead to obstruction of the bile ducts in some cases, monitoring bilirubin levels alone is not sufficient to diagnose pancreatic damage.

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The nurse is caring for a client who experienced multiple invasive trauma from a motor vehicle collision and has developed systemic inflammatory response syndrome (SIRS). Which pathophysiological process is most likely associated with the development of SIRS in this client?

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Correct Answer is B

Explanation

The nurse is assessing a client with a gunshot wound to the abdomen who is admitted to the intensive care unit (ICU) following a 3-hour surgical procedure. Which elevated laboratory value indicates pancreatic damage?

Correct Answer is A

Explanation

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