The nurse should recognize which response is the immune system's reaction to a source of inflammation?

Activation of exocytosis.

Vasoconstriction.

Decreased histamine production.

Increased vascular permeability.

Answer and Explanation

The Correct Answer is D

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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Correct Answer is A

Explanation

A. Accessibility to trauma care. In rural communities, access to trauma care is critical because emergency medical services (EMS) response times are often delayed due to long travel distances. Without nearby trauma centers, patients with life-threatening injuries, such as those from motor vehicle accidents or farm-related injuries, face higher mortality and morbidity rates. Ensuring rapid access to trauma care significantly improves survival outcomes.
B. Family planning center. While family planning services are important for reproductive health, they are not as immediately life-saving as access to trauma care in an emergency.
C. Annual health fair. Health fairs provide preventive education and screenings, which are beneficial but do not address immediate, life-threatening medical needs.
D. Weather-related disaster plan. While a disaster plan is important for emergency preparedness, trauma care is a more immediate and ongoing concern in rural settings, where high-risk injuries require timely medical intervention.

A. Immobility B. Obesity C. Inadequate nutritional intake D. Incontinence E. Decreased sensory perception F. Coarse lung sounds G. Diabetes mellitus

Correct Answer is ["A","B","C","D","E","G"]

Explanation

A. Immobility. The client requires a walker for mobility and reports difficulty repositioning in bed. Limited mobility increases the risk of pressure injuries due to prolonged pressure on certain areas, reducing blood flow and oxygen delivery to the skin.
B. Obesity. The client has a history of moderate obesity, which increases skin friction, moisture retention, and difficulty with self-care. Excess weight places additional pressure on bony prominences, elevating the risk of pressure ulcers.
C. Inadequate nutritional intake. The client has a poor appetite and decreased oral intake, which can lead to protein and nutrient deficiencies. Poor nutrition impairs skin integrity and delays wound healing, further increasing the risk of pressure injuries.
D. Incontinence. The client wears an incontinence brief due to occasional urinary and fecal accidents. Constant exposure to moisture from urine and stool can break down the skin barrier, making it more susceptible to infections and pressure injuries.
E. Decreased sensory perception. The client reports neuropathy in both hands and lower legs, reducing sensation. Impaired sensation can prevent the recognition of pressure, pain, or injury, leading to delayed intervention and increased risk of skin breakdown.
F. Coarse lung sounds. While coarse lung sounds may indicate respiratory congestion or infection, they do not directly contribute to skin injury risk. This factor is less relevant compared to others affecting skin integrity.
G. Diabetes mellitus. The client has poorly controlled type 1 diabetes, which impairs circulation and delays wound healing. Chronic hyperglycemia can lead to reduced immune response and increased susceptibility to infections and pressure ulcers.

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The nurse should recognize which response is the immune system's reaction to a source of inflammation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The public health nurse is evaluating resources in a rural community. Which healthcare resource is most important to the community?

Correct Answer is A

Explanation

Exhibits The nurse reviews the client's data. Which factor(s) place the client at greatest risk for skin injuries? Select all that apply.

Correct Answer is ["A","B","C","D","E","G"]

Explanation

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