The nurse is caring for a patient with gastroenteritis. He not only has diarrhea and dehydration but also complains of feeling very warm. What systemic response may the patient experience with this inflammatory infection?

Redness of the anus

Stomatitis

Intestinal inflammation

Increased body temperature

Answer and Explanation

The Correct Answer is D

Choice A reason: Redness of the anus is a local response to irritation from frequent diarrhea in gastroenteritis, not a systemic response. Systemic responses involve the whole body, like fever, driven by cytokine release. Anal redness is a localized tissue reaction, not reflective of the broader inflammatory process in this infection.

Choice B reason: Stomatitis, or mouth inflammation, is not a systemic response to gastroenteritis. It may occur in specific infections (e.g., herpes) but is not typical in gastroenteritis, which primarily affects the intestines, causing diarrhea and dehydration. Systemic responses involve fever or leukocytosis, not localized oral inflammation, making this choice incorrect.

Choice C reason: Intestinal inflammation is a local response in gastroenteritis, causing diarrhea and abdominal pain. Systemic responses, like fever, result from cytokines (e.g., IL-1, IL-6) released during infection, affecting the entire body. Intestinal inflammation is the primary pathology, not a systemic effect, so this does not fit the question’s focus.

Choice D reason: Increased body temperature (fever) is a systemic response to gastroenteritis, triggered by cytokines (e.g., IL-1, TNF) released during infection. These signal the hypothalamus to raise body temperature, enhancing immune response. The patient’s feeling of warmth aligns with fever, a common systemic manifestation of inflammatory infections like gastroenteritis.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: CPTT (likely a typo for aPTT, activated partial thromboplastin time) measures clotting time in the intrinsic pathway, used to monitor heparin therapy. It does not detect protein fragments from fibrinolysis. In DVT, aPTT is normal unless anticoagulation is involved, making it unhelpful for detecting fibrin degradation products.

Choice B reason: INR (international normalized ratio) assesses the extrinsic clotting pathway, primarily for warfarin monitoring. It does not measure fibrin degradation products like D-dimer. In DVT, INR is typically normal unless the patient is on anticoagulants, so it is not useful for confirming fibrinolysis or diagnosing DVT.

Choice C reason: Impedance plethysmography is a non-invasive test measuring blood flow changes in veins, used to detect DVT by identifying obstructions. It does not measure protein fragments or fibrinolysis products. It assesses physical blood flow, not biochemical markers, making it irrelevant for detecting fibrin degradation in DVT.

Choice D reason: D-dimer is a specific test for fibrin degradation products, elevated in DVT due to fibrinolysis of clots. A high D-dimer indicates active clot breakdown, supporting DVT diagnosis. It is sensitive but not specific, requiring imaging confirmation, but it directly addresses the question of detecting protein fragments from fibrinolysis.

A. Fluid imbalance associated with excessive blood component replacement B. Risk for impaired skin integrity associated with ischemia or bleeding C. Risk for hypervolemia associated with bleeding D. Anxiety associated with uncertain prognosis and risk for death

Correct Answer is C

Explanation

Choice A reason: Fluid imbalance is appropriate, as DIC involves bleeding and clotting, requiring blood component replacement (e.g., platelets, plasma). This can disrupt fluid balance, causing hypovolemia from bleeding or overload from transfusions. Monitoring and managing fluid status is critical to prevent complications like shock or edema in DIC patients.

Choice B reason: Risk for impaired skin integrity is relevant, as DIC causes microthrombi, leading to tissue ischemia, and bleeding, causing bruising or petechiae. These increase the risk of skin breakdown, especially in prolonged immobility. This diagnosis addresses potential complications from DIC’s vascular and hemorrhagic effects, requiring skin monitoring and care.

Choice C reason: Risk for hypervolemia associated with bleeding is incorrect, as bleeding in DIC causes hypovolemia, not hypervolemia. Fluid overload may occur from excessive transfusions, but bleeding itself reduces volume. This diagnosis is inaccurate, as DIC’s primary fluid issue is loss, not excess, making it inappropriate for the care plan.

Choice D reason: Anxiety is a valid diagnosis in DIC due to its life-threatening nature and uncertain prognosis. Patients may experience fear from bleeding, organ failure risks, or hospitalization. Addressing anxiety through support and communication is appropriate, as it impacts psychological well-being and coping during this critical illness, supporting holistic care.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a patient with gastroenteritis. He not only has diarrhea and dehydration but also complains of feeling very warm. What systemic response may the patient experience with this inflammatory infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has symptoms suspicious of deep vein thrombosis. Which lab test would be helpful to see if higher-than-normal amounts of protein fragments secondary to fibrinolysis are present in the blood?

Correct Answer is D

Explanation

A nurse is caring for a patient with disseminated intravascular coagulation (DIC). Which nursing diagnosis should not be included in this patient’s plan of care?

Correct Answer is C

Explanation

A nurse is assessing a patient who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?

A nurse is caring for a patient with deep vein thrombosis. The nurse would expect all of the following orders to be on the care plan, except:

A patient is experiencing syndrome of inappropriate antidiuretic hormone secretion (SIADH). What does the nurse expect that the lab work will show?

A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in the patient’s plan of care to promote healing?

The nurse analyzes the laboratory results of a patient with hemophilia. The nurse understands that which result will most likely be abnormal in this patient?

A nurse is caring for a patient who has secondary obesity. Which condition is the most likely to result in secondary obesity?

The nurse is creating a plan of care to prevent venous thrombosis for a patient after orthopedic surgery. Which appropriate nursing intervention will the nurse include in the plan of care?

A patient with a 20-year history of hypothyroidism who has not been compliant with taking thyroid replacement therapy is brought into the ED with a diagnosis of myxedema coma. Which symptoms are consistent with this life-threatening event? (Select all that apply)