The nurse is explaining to a client the reasons why a burn wound becomes infected. Which reason(s) should the nurse include? (Select all that apply)

Organisms on the skin before the burn colonize in burn wounds and under eschar.

Epithelium that produces antimicrobial peptides is reduced.

An increased basal metabolic rate and body heat radiation stresses the immune system.

Acidic nature of skin that protects against bacterial invasion is compromised.

Loss of serum proteins alters the humoral components.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Pre-existing skin organisms, like Staphylococcus, colonize burn wounds and eschar, thriving in damaged tissue with impaired barriers. Burns disrupt skin integrity, allowing microbial invasion and biofilm formation, increasing infection risk. This is a primary reason for burn wound infections, supported by wound care microbiology.

Choice B reason: Burned epithelium loses its ability to produce antimicrobial peptides, which normally inhibit bacterial growth. This reduction weakens local defenses, allowing pathogens to proliferate in the wound. Compromised epithelial function is a key factor in burn infections, as it diminishes the skin’s innate immune response.

Choice C reason: Increased basal metabolic rate and heat radiation in burns elevate systemic stress but do not directly cause wound infections. While metabolism impacts healing, it is not a primary infection driver. Local factors like microbial colonization and loss of skin barriers are more directly responsible for burn wound infections.

Choice D reason: The skin’s acidic pH, which inhibits bacterial growth, is compromised in burns due to tissue destruction. This loss of the protective acid mantle allows pathogens to invade more easily, increasing infection risk. This is a critical pathophysiological reason for burn wound susceptibility, per dermatological infection models.

Choice E reason: Loss of serum proteins in burns, due to exudative leakage, impairs humoral immunity, including complement and antibody function. This weakens systemic defenses against wound pathogens, increasing infection risk. Protein loss is a recognized factor in burn-related immunosuppression, contributing to the high incidence of wound infections.

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Correct Answer is A

Explanation

Choice A reason: In hypothyroidism, elevated TSH reflects the pituitary’s attempt to stimulate an underactive thyroid, often causing goiter due to glandular hypertrophy. TSH rises to compensate for low thyroid hormone production, leading to thyroid enlargement. This aligns with the pathophysiology of goiter in primary hypothyroidism, supporting the clinical finding.

Choice B reason: Iodine levels are not routinely measured in hypothyroidism and do not directly cause goiter. Iodine deficiency may contribute to goiter but is less common in developed regions. Elevated TSH, not iodine, drives thyroid enlargement in hypothyroidism, making this an incorrect marker for supporting the goiter finding.

Choice C reason: Calcium levels are unrelated to goiter or hypothyroidism unless parathyroid dysfunction is involved. Goiter results from TSH-driven thyroid hypertrophy due to low thyroid hormones. Calcium does not influence thyroid enlargement, making it an irrelevant laboratory result for supporting the client’s goiter in this context.

Choice D reason: Serum T3 and T4 are decreased in hypothyroidism, not increased, as the thyroid fails to produce adequate hormones. Low T3/T4 triggers high TSH, causing goiter. Increased T3/T4 would suggest hyperthyroidism, not hypothyroidism with goiter, making this an incorrect choice for supporting the clinical finding.

A. Bone reabsorption exceeds bone formation which leads to an increase in bone fragility. B. Repetitive stress initiates a cascade leading to protease destruction of joints’ cartilage surfaces. C. T-cells generate cytokine production and antigen-antibody reactions that trigger inflammatory responses. D. Imbalance of uric acid metabolism deposits urate crystals in joint tissues which leads to inflammation.

Correct Answer is C

Explanation

Choice A reason: Bone reabsorption exceeding formation describes osteoporosis, not rheumatoid arthritis. RA involves autoimmune inflammation of synovial joints, driven by cytokines and T-cells, not primary bone fragility. This choice is incorrect, as it misrepresents RA’s immune-mediated synovial pathology with a bone density disorder.

Choice B reason: Repetitive stress may cause osteoarthritis, not RA. RA is an autoimmune condition where T-cells and cytokines attack synovium, causing inflammation and cartilage damage. Stress may exacerbate symptoms, but it is not the primary mechanism, making this incorrect for RA’s pathophysiological explanation.

Choice C reason: RA’s pathophysiology involves T-cells producing cytokines (e.g., TNF-α) and antigen-antibody reactions, triggering synovial inflammation. This autoimmune process causes wrist swelling and joint damage, as seen in the client. This mechanism accurately explains RA’s inflammatory nature, per rheumatology evidence, and is appropriate for client education.

Choice D reason: Uric acid imbalance and urate crystal deposition cause gout, not RA. RA is driven by autoimmune T-cell and cytokine activity, not crystal-induced inflammation. This choice is incorrect, as it describes a different arthritic condition unrelated to the client’s autoimmune rheumatoid arthritis pathology.

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The nurse is explaining to a client the reasons why a burn wound becomes infected. Which reason(s) should the nurse include? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

During an assessment, the nurse determines that a client with hypothyroidism has a goiter. An increase in which laboratory test result(s) supports this finding?

Correct Answer is A

Explanation

A female client with rheumatoid arthritis (RA) comes to the clinic with swelling of her wrists after she braced herself against a fall in the bathroom. Which pathophysiological mechanism should the nurse explain to the client regarding RA?

Correct Answer is C

Explanation

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A client is admitted with gastrointestinal (GI) bleeding and a flat plate of the abdomen reveals an orange-sized mass in the stomach. After identifying the mass upon palpation of the abdomen, which location should the nurse document this finding?

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