Which histologic finding in an affected area of the body suggests the presence of an inflammatory process?

Increase in monocytes and macrophages.

Predominance of megakaryocytes.

Presences of fibroblasts and collagen.

Prevalence of dead neutrophils.

Answer and Explanation

The Correct Answer is A

A. Increase in monocytes and macrophages. Monocytes and macrophages are key immune cells involved in the inflammatory response. Monocytes migrate to the affected tissue, where they differentiate into macrophages and help clear pathogens, dead cells, and debris. Their presence indicates an ongoing or chronic inflammatory process.
B. Predominance of megakaryocytes. Megakaryocytes are large bone marrow cells responsible for platelet production. They are not involved in inflammation and are typically found in the bone marrow, not in inflamed tissues.
C. Presence of fibroblasts and collagen. Fibroblasts and collagen are associated with tissue repair and scar formation rather than active inflammation. Their presence suggests healing and fibrosis rather than an acute inflammatory response.
D. Prevalence of dead neutrophils. Dead neutrophils are a hallmark of pus formation (suppuration) in bacterial infections but do not necessarily indicate ongoing inflammation. Neutrophils are the first responders in acute inflammation, but their presence alone does not define an inflammatory process—the presence of active immune cells like macrophages is more indicative.

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Correct Answer is D

Explanation

A. Offer to also administer a meningococcal vaccine to the client. The meningococcal vaccine is not routinely recommended for older adults unless they are at increased risk (e.g., immunocompromised, asplenic, or in certain outbreak situations). The priority is ensuring the influenza vaccine is appropriate based on the client’s history.
B. Record height, weight, and vital signs before giving the vaccine. Routine height, weight, and vital signs are not necessary before administering an influenza vaccine unless the client has symptoms of illness. The focus should be on vaccination history and contraindications.
C. Ask if the client's influenza exposure was within the last week. Recent exposure to influenza does not contraindicate vaccination. The vaccine is preventive and does not provide immediate protection, so the client should still receive it to help prevent future infection.
D. Review the client's vaccination history in the electronic record. Checking vaccination history ensures the client is receiving the correct vaccine and has not already been vaccinated for the season. This helps prevent unnecessary repeat doses and ensures adherence to recommended immunization schedules.

Correct Answer is []

Explanation

Potential Conditions

Wound healing by secondary intention (Correct): This occurs when the wound is left open to heal from the inside out due to extensive tissue loss, high infection risk, or inability to approximate wound edges. The client’s wound is large, packed with gauze, and not sutured, indicating it is healing by secondary intention.

Wound healing by primary intention (Incorrect): Primary intention healing occurs when wound edges are surgically approximated with sutures or staples, allowing faster healing with minimal scarring. Since the client’s wound is open and packed, this is not the correct choice.

Actions to Take

Use sterile procedure to change dressing (Correct): Using sterile technique reduces the risk of infection and promotes wound healing, which is crucial for open wounds healing by secondary intention.

Encourage the client to consume a balanced diet (Correct): Proper nutrition, especially with protein, vitamin C, and zinc, enhances wound healing by supporting tissue regeneration and immune function.

Culture the wound (Incorrect): A wound culture is only necessary if there are signs of infection, such as increased drainage, foul odor, or worsening erythema. Since there is no mention of infection in the scenario, culturing the wound is not an immediate action.

Parameters to Monitor

Drainage on the dressing (Correct): Monitoring drainage helps assess healing progress and detect infection. An increase in purulent, foul-smelling, or discolored drainage may indicate complications.

The formation of granulation tissue (Correct): Granulation tissue, which is pink and bumpy, indicates healthy wound healing. Lack of granulation tissue suggests delayed healing.

Blood pressure (Incorrect): While blood pressure monitoring is important for overall health, it does not directly indicate wound healing progress.

Intake and output (Incorrect): Although hydration is important for healing, tracking intake and output is more relevant for clients at risk of fluid imbalances rather than wound healing assessment.

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Which histologic finding in an affected area of the body suggests the presence of an inflammatory process?

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Naxlex Comprehensive Predictor Exams

An older adult client comes to a free vaccination clinic requesting an influenza vaccination. Which action should the nurse implement?

Correct Answer is D

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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