Exam 2 Nursing 120 Study Guide QUESTIONS AND
ANSWERS WITH VERIFIED SOLUTIONS
The inflammatory response - ANSWER is a sequential reaction to cell injury.
It neutralizes and dilutes the inflammatory agent, removes necrotic materials,
and establishes an environment suitable for healing and repair.
The mechanism of inflammation - ANSWER is basically the same regardless of
the injuring agent. The intensity of the response depends on the extent and
severity of injury and on the reactive capacity of the injured person.
The inflammatory response can be divided into - ANSWER a vascular response,
a cellular response, formation of exudate, and healing.
The vascular response results in - ANSWER vasodilation causing hyperemia
(increased blood flow in the area) and increased capillary permeability. These
actions result in redness, heat, and swelling at the site.
During the cellular response - ANSWER neutrophils and monocytes move to
the inner surface of the capillaries and then through the capillary wall to the site
of injury.
• Nursing Assessment includes: - ANSWER Health history including nutrition,
infections, immunizations, allergies, autoimmune disorders, cancer, and chronic
illness, physical exam, including lymph node assessment in addition to other body
systems
,Nurses role is to: - ANSWER offer support, reduce anxiety, patient education
and counseling
Diagnostic Tests - ANSWER WBC count and differential,
bone marrow biopsy,
humoral and cellular immunity tests,
phagocytic cell function test,
complement component tests,
hypersensitivity tests,
specific antigen-antibody tests,
HIV infection tests
Standard Precautions - ANSWER designed for the care of all patients in
hospitals and health care facilities
Transmission Precautions - ANSWER Airborne precaution - used for infections
spread in small particles in the air such as chickenpox, measles, and TB
Droplet precaution - used for infections spread in large droplets by coughing,
talking or sneezing such as influenza and bacterial meningitis
Contact precautions - used for infections spread by skin-to-skin contact or contact
or contact with other surfaces such as C diff, MRSA, and VRE
HAI bloodstream infection: CLABSI- - ANSWER Bundle approach:1) hand
hygiene, 2) maximal barrier precaution 3) chlorhexidine skin antisepsis 4) optimal
catheter site selection 5) daily review of line necessity with prompt removal of
unnecessary lines
,HAI CAUTI - ANSWER Early catheter removal only use urinary catheter when
required, meticulous perineal care, nursing interventions to ensure infection risk
minimized
Community-acquired infections - - ANSWER Collaborate effect of CDC, state
and local public health departments, Methods: sanitation techniques, regulated
health practices, food preparation, immunization program
Inflammatory Response - ANSWER Local manifestations: redness, heat, pain,
swelling, loss of function
Systemic manifestations - lab test: Increased WBC count " shift to the left" ( CBC
with differential shows elevated WBC count with high number of immature
neutrophils) Malaise, Nausea and anorexia, Increased pulse and respiratory rate,
fever
Acute inflammation - ANSWER the healing occurs in 2-3wk and usually leaves
no residual damage
Subacute inflammation - ANSWER has the features of the acute process but
lasts longer.
Chronic inflammation - ANSWER lasts for weeks, months or even years. The
injurious agent persists or repeatedly injures tissues.
Nursing Management -Health Promotion - - ANSWER Prevention of injury,
adequate nutrition and hydration, early recognition of inflammation, immediate
treatment
, Treating inflammation - ANSWER • antihistamines,
sympathomimetic/decongestant drugs, corticosteroids, antipruritic drugs and
mast cell stabilizing drugs
Type 4 contact dermatitis (Allergic reaction) - ANSWER is caused by the
chemicals used in the manufacturing process of latex drugs. It is a delayed
reaction that occurs within 6-48 hours. Typically, the person first has dryness,
pruritus, fissuring and cracking of the skin following by redness swelling and
crusting
Type 1 (Allergic reaction) - ANSWER is a response to the natural rubber latex
protein and occurs within minutes of contact with the proteins. Vary from skin
redness, urticaria, rhinitis, conjunctivitis or asthma to full blown anaphylactic
shock
Anaphylaxis - ANSWER Occurs suddenly in hypersensitive patients after
exposure to the offending allergen. 1)recognizing signs and symptoms of an
anaphylactic reaction, 2) maintaining a patent airway, 3) giving drugs, 4) treating
for shock o Emergency Management
Emergency management in case of allergic reaction - ANSWER • Initial - ensure
patent airway, intubation if evidence of impending obstruction, remove insect
stinger if present, establish IV access, Epinephrine IM Can repeat every 5-15 mins,
Give high flow o2 via face mask, Nebulized albuterol from bronchospasm resistant
to epinephrine, Diphenhydramine IV for urticaria and itching, Corticosteroid
• Hypertension - place recumbent and elevate legs, IV normal saline rapid bolus of
1-2L , Maintain BP with fluid, volume expanders, vasopressor