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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Auscultate for bowel sounds. While monitoring for postoperative ileus is important, it is not the priority intervention in a patient who is suddenly confused and lethargic after hip surgery. Avascular complications, fat embolism, or deep vein thrombosis (DVT) are more immediate concerns.
B. Compare pedal pulses bilaterally. A sudden change in mental status after hip arthroplasty could indicate a fat embolism or deep vein thrombosis (DVT) leading to pulmonary embolism. Comparing bilateral pedal pulses helps assess for signs of vascular impairment or embolic complications, which are serious postoperative risks. Fat embolism syndrome (FES) can cause confusion, lethargy, and respiratory distress, requiring immediate intervention.
C. Observe the surgical incision. While assessing for infection or bleeding is important, these complications do not typically cause sudden confusion and lethargy. Systemic embolic events or impaired circulation are more critical to assess first.
D. Assess mobility of the right leg. Evaluating mobility is part of routine post-arthroplasty care, but it does not directly address the sudden mental status changes seen in this patient. Assessing circulation and embolic risk takes priority.
Correct Answer is ["C","D","F","G"]
Explanation
Heart rate 88 beats/minute: This is within the normal range (60-100 bpm) and does not require immediate intervention.
Blood pressure 122/72 mm Hg: This is within a normal range and does not indicate an urgent issue.
Temperature 100.5°F (38°C): An elevated temperature suggests a possible infection, such as cellulitis or deep vein thrombosis (DVT), which requires further evaluation.
Reports of pain with ambulation: Pain with walking, especially in a client with peripheral vascular disease and diabetes, may indicate worsening circulation, infection, or DVT.
Respirations 20 breaths/minute: This is within the normal range (12-20 breaths/minute) and does not require immediate intervention.
Left lower leg with erythema, warm, and swollen: These are signs of inflammation or infection, such as cellulitis or a possible DVT, both of which require urgent medical attention.
Blood glucose 252 mg/dL (13.9 mmol/L): Elevated blood glucose can impair wound healing, increase the risk of infection, and contribute to further complications in a client with diabetes.
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