Nokea
When planning this patients care, which of the following statements regarding acute inflammation should you recognize?
- A. Inflammation is essentially synonymous with infection.
- B. Inflammation may impair the healing process.
- C. Inflammation is a defensive reaction intended to remove an offending agent.
- D. Inflammation inhibits the release of histamines in the tissues.
Correct Answer: C
Rationale: Inflammation is a defensive reaction intended to remove an offending agent and prepare the site for repair. Inflammation is not the same as infection, it does not impair the healing process, and it does not inhibit the release of histamines in the tissues.
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What is the best outcome you can expect for this patient?
- A. Patient will adopt coping mechanisms to reduce stress.
- B. Patient will be stress free for the duration of treatment.
- C. Patient will avoid all stressful situations.
- D. Patient will be treated with an antianxiety agent.
Correct Answer: A
Rationale: Stress management is directed toward reducing and controlling stress and improving coping. The outcome for this diagnosis is that the patient needs to adopt coping mechanisms that are effective for dealing with stress, such as relaxation techniques. The other options are incorrect because it is unrealistic to expect a patient to be stress free; avoiding stressful situations and starting an antianxiety agent are not the best answers as outcomes for ineffective coping.
What can the triage nurse teach the mother?
- A. The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection.
- B. Bee stings frequently cause infection, pain, and swelling, and, with treatment, the infection should begin to subside late today.
- C. The infection was probably caused by the stinger, which may still be in the wound.
- D. The mothers assessment is accurate and the ED doctor will probably prescribe antibiotics to fix the problem.
Correct Answer: A
Rationale: Cells or tissues of the body may be injured or killed by any agent (physical, chemical, infectious). When this happens, an inflammatory response (or inflammation) naturally occurs in the healthy tissues adjacent to the injury site. Inflammation is not the same as infection. An infectious agent is only one of several agents that may trigger an inflammatory response. Although bee stings may cause infection, the signs and symptoms (very painful, looks swollen and red) result from the acute inflammatory response. If the stinger were still in the wound, it would only be creating inflammation, not infection. Antibiotics are not indicated.
Which of the following constitute negative feedback loops? Select all that apply.
- A. Serum glucose levels
- B. Acid-base balance
- C. Temperature
- D. Blood clotting
- E. Labor onset
Correct Answer: A,B,C
Rationale: These mechanisms work by sensing deviations from a predetermined set point or range of adaptability and triggering a response aimed at offsetting the deviation. Blood pressure, acid-base balance, blood glucose level, body temperature, and fluid and electrolyte balance are examples of functions regulated through such compensatory mechanisms. Coagulation and labor onset are results of positive feedback loops.
What principle of stress and adaptation should be integrated into the nurses plan of care for this patient?
- A. Adaptation often fails during stressful events and results in homeostasis.
- B. Stress is a part of all lives, and, eventually, this young woman will adapt.
- C. Acute anxiety and depression can be adaptations that alleviate stress in some individuals.
- D. An accumulation of stressors can disrupt homeostasis and result in disease.
Correct Answer: D
Rationale: Four conceptsâ??constancy, homeostasis, stress, and adaptationâ??are key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic, and hormonal measures; stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis, and, if adaptation fails, the result is disease. If a person is overwhelmed by stress, he or she may never adapt. Acute anxiety and depression are frequently associated with stress.
You can expect that his sympathetic nervous system has stimulated his adrenal gland to release what?
- A. Endorphins
- B. Dopamine
- C. Epinephrine
- D. Testosterone
Correct Answer: C
Rationale: In the sympathetic-adrenal-medullary response to stress, the sympathetic nervous system stimulates the adrenal gland to release epinephrine and norepinephrine.