Nursing Care: Altered Inflammation

Prepare: The Nursing Care of Altered Inflammation

Infection and Inflammation

• Which statement regarding infection and inflammation is correct?

Process of Healing

• Adam is a 22-year-old student who loves to skateboard and spend time outside. Recently while skateboarding, Adam fell, breaking his wrist. After surgery to repair his wrist, Adam’s incision was sutured closed. This is an example of which process of healing?

Negative Pressure Wound Therapy

• Which statement best describes negative pressure wound therapy (NPWT)?

Self-Check: Assessment

• The nurse is assessing Adam’s incision from his wrist surgery. Which descriptive words would be appropriate to include in the nurse’s assessment note? Select all that apply.

Self-Check: Adam's Assessment

Soft Tissue Injury

• During Adam’s initial fall injury, he also sprained his ankle. Which intervention is most appropriate for Adam and his soft tissue injury?

Assessments

• Prior to applying compression to Adam’s ankle, what assessments would be important for the nurse to complete? Select all that apply.

The Infectious Process

• Which statement, made by Adam, is most concerning?

Self-Check: Dehiscence Risk Factors

• Which factors would increase a client’s risk of developing a wound dehiscence? Select all that apply.

Reflect: The Nursing Care of Altered Inflammation

Keloid Scarring

• Maya, a 24-year-old student, is at her university’s health clinic. She is asking about intervention options for various keloid scars on her ears and neck. Which statement, made by the clinic’s nurse, is most accurate?

Dietary Requirements

• Adam asks the nurse about dietary requirements to help his injuries heal more efficiently. Which of the following recommendations made by the nurse is most appropriate?

Delegation

• Match the appropriate task to the most appropriate colleague. Some colleagues may be used more than once.

Hyperthermia

• Upon assessment, the nurse finds that Adam has developed a fever of 102.6 degrees F. What interventions are most appropriate to decrease his temperature?

Classifications

• Review the client’s nurses notes. Match the client with their appropriate classification. Click the patient in the right column, then click the appropriate classification in the left column.

Negative Pressure Wound Therapy

A client is having a negative pressure wound therapy (NPWT) device placed on their dehisced abdominal wound. What important aspects should the nurse be aware of? Select all that apply.

Outcomes and Goals

• The nurse identifies a nursing diagnosis of impaired tissue integrity for Adam. Which statements below are appropriate and realistic goals and outcomes? Select all that apply.

Wound Dressings

• The nurse is performing a dressing change on a client with the assistance of a student nurse. The wound is malodorous, with purulent and serosanguineous drainage on the old dressing. Which of the following statements made by the student nurse requires the nurse to intervene?

Pressure Ulcers

Prepare: Pressure Ulcers

Pressure Ulcer Risk Factors

• What are common risk factors associated with pressure ulcer development? Select all that apply.

Ulcer Classifications

• Which of the following descriptions is discussing a stage II pressure ulcer?

Ulcer Classifications

• What are common locations for pressure ulcers/sores? Select all that apply.

Self-Check: Nursing Actions - Pressure Ulcer Prevention

• Jan has arrived to the medical surgical unit from the nursing home where she resides. She has a history of a previous right sided stroke that left her with some musculoskeletal and neurologic deficits. Which of the following nursing actions would be most helpful in preventing Jan from developing a pressure ulcer?

Self-Check: Suspected Deep Tissue Injury

• How will the nurse best assess the client for a suspected deep tissue injury if they have darker skin tones?

Self-Check: Wound Descriptions

• Which of the following descriptions is best for this wound?

Self-Check: Delayed Wound Healing

• Which of the following factors play a role in delaying wound healing? Select all that apply.
• A nurse is helping a student nurse change a pressure ulcer dressing on a client’s heel. The nurse will need to intervene when which of the following actions is observed?

Reflect: Pressure Ulcers

Ulcer Stages

• Match the ulcer stages to the correct descriptions. Click a stage in the left column, then click the matching description in the right column.

Braden Scale

• You are taking care of Jan. She responds to verbal commands, but cannot always say that she is uncomfortable or that she needs to be repositioned. You notice that Jan never eats a complete meal and rarely finishes more than half of her food tray at mealtimes. While she can make slight adjustments to her position occasionally, she requires moderate assistance when moving and frequently slides down in the bed or chair. She cannot bear weight to stand or ambulate. Her bed linens are changed at least once a shift due to increased sweating and perspiration. Select the values for Jan’s Braden Scale score.

Prevention

• Monica, Jan’s daughter, is visiting her in the hospital. She asks the nurse how to prevent her mother from developing further pressure ulcers in the future when she returns to the nursing home. Which of the following recommendations does the nurse give to Monica? Select all that apply

Nursing Diagnosis

• Based on your previous assessments of Jan, you come up with the nursing diagnosis of ‘impaired skin integrity.’ What information lead to this diagnosis? Select all that apply.

Goals

• Which goal will the nurse include in Jan’s plan of care?

Complication

• A few months after discharge, Jan returns to the hospital with flu-like symptoms, having spent most of her time in bed over the last week. The nurse assesses Jan and finds an open area on her sacrum that is draining moderate amounts of thick, yellow-tan fluid with an unpleasant odor. Which documentation is best for Jan’s exudate?

Dressing Change

• After premedicating Jan, the nurse prepares for the dressing change. Which of the following supplies are required? Select all that apply.

Dressing Change

• The nurse is getting ready to change Jan’s pressure wound dressing. Which of the following prescriptions is most appropriate prior to the dressing change

Nursing Care: Altered Immune Response

Prepare: The Nursing Care of Altered Immune Response

Altered Immune Response

• What is the best example of artificial passive acquired immunity?

Immunoglobulins: Altered Immune Response

• What type of immunoglobulin increases in numbers when the body is exposed to an allergen?

Altered Immune Response

• What is the best example of active acquired immunity?

Self-Check: Altered Immune Response

What is the best example of a natural passive immunity.

Self-Check: Diagnostic Studies - Altered Immune Response

• What diagnostic study will help assess for pathogens in the respiratory system?

Self-Check: Assessment: Allergies

• What assessment data is needed to determine the risk factors that can predispose your client to develop any allergic reaction? Select all that apply.

Self-Check: Pharmacotherapy: Altered Immune Response

• A client is admitted due to an allergic reaction secondary to acute asthma exacerbation. Albuterol via nebulizer was given to open the bronchi. What medication can you expect to be given next that will help to reduce inflammation?
• A client came into the emergency department due to severe allergic reaction after taking penicillin. The client’s blood pressure is 90/50 mm Hg. What is the medication that can stabilize the blood pressure?

Reflect: The Nursing Care of Altered Immune Response

Altered Immune Response

• What type of apheresis procedure is the removal of leukocytes in the blood?

Interprofessional Care Management: Altered Immune Response

• A client is admitted due to severe allergic reaction related to a bee sting. What are nursing actions that will help to manage this client? Select all that apply.

Altered Immune Response

• What electrolyte imbalance can citrate toxicity cause?

Plasmapheresis

• What are the most common complications of plasmapheresis? Select all that apply.

Organ Transplant

• What are the organs that can be used for transplant? Select all that apply.

Altered Immune Response

• What is the most common complication of anaphylactic reaction?

Ethics: Organ Donation

• A client died due to motor vehicular accident. The client is not an organ donor. Based on the past medical history and clinical condition, the client can donate corneas. Who can sign the document for the cornea to be donated?

Organ Transplant

• What type of transplant rejection happens within 24 hours?

HIV

Prepare: HIV

Assessment: Human Immunodeficiency Virus

• What are the clinical manifestations of a human immunodeficiency virus (HIV) positive client who might have a compromised immune system? Select all that apply.

Complications of Human Immunodeficiency Virus

• What are the most common complications of human immunodeficiency virus (HIV)? Select all that apply.

Assessment: Human Immunodeficiency Virus

• What are the risk factors of human immunodeficiency virus (HIV)? Select all that apply.

Self-Check: Transmission of HIV

• What are the modes of transmission of human immunodeficiency virus (HIV)?

Self-Check: Nursing Process – Lifestyle

• The client verbalized that she is dating different men, engaged in unsafe sexual behaviors, and uses recreational drugs from time to time. Based on the assessment findings, what are the appropriate nursing diagnoses? Select all that apply.

Self-Check: Health Teaching

Health Teaching: Human Immunodeficiency Virus

• A 21-year-old visitor of the client in room 3 in the emergency department asked the nurse if it is possible that if her boyfriend never had sexual intercourse means that he does not have human immunodeficiency virus (HIV). What is the most appropriate nursing response?

Self-Check: Health Teaching

Health Teaching: Human Immunodeficiency Virus

• A client visited the urgent care due to sporadic episodes of diarrhea secondary to human immunodeficiency virus (HIV). The client is concern about the transmission of HIV to his partner. What is the most appropriate health teaching to this client?

Self-Check: Acute HIV Infection

• A client has acquired acute human immunodeficiency virus (HIV) infection after having sexual intercourse with an infected partner. What is the expected findings with an acute infection?

Reflect: HIV

Interprofessional Care Management: Human Immunodeficiency Virus

• The client is admitted due to dehydration is human immunodeficiency virus (HIV) positive. The client’s vital signs are temperature 97 degrees Fahrenheit, BP 90/50 mm Hg, HR 105 beats/minute, RR 22 breaths/minute and oxygen saturation 90% in room air. The client is receiving antiretroviral therapy. However, the laboratory findings showed that WBC 3000/mm3, hematocrit 37%, CD4 350 cells/microliter and elevated viral load. Based on the assessment findings, what are the appropriate nursing actions?

Nursing Process: Human Immunodeficiency Virus

• The client is admitted due to dehydration secondary to human immunodeficiency virus (HIV). The client’s vital signs are temperature 97 degrees Fahrenheit, BP 90/50 mm Hg, HR 105 beats/minute, RR 22 breaths/minute and oxygen saturation 90% in room air. The client is receiving antiretroviral therapy. However, the laboratory findings showed that WBC 3000/mm3, hematocrit 37%, CD4 350 cells/microliter and elevated viral load. Based on the assessment findings, what are the appropriate nursing diagnoses?

Neutropenic Precautions: Human Immunodeficiency Virus

• The client with human immunodeficiency virus (HIV) is on neutropenic precautions. What is the most appropriate nursing action to reinforce neutropenic precautions?

Acquired Immunodeficiency Syndrome

• What laboratory finding supports that a client with a human immunodeficiency virus (HIV) infection has developed Acquired Immunodeficiency Syndrome (AIDS)?

Complications of Human Immunodeficiency Virus

• The client is admitted due to dehydration and the client has human immunodeficiency virus (HIV). Hepatitis panel was drawn. Based on the results, the client hepatitis B and C are positive. What precautionary measures should be used by the nurse?

Health Teaching: Human Immunodeficiency Virus

• The client is admitted with acute human immunodeficiency virus (HIV) infection. The client verbalized that she is concerned about keeping up the time when to take her pills. What is the most appropriate nursing action?

Therapeutic Communication: Human Immunodeficiency Virus

• A client who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, “I feel that there’s no hope for me”. Which response by the nurse is appropriate?

Health Prevention: Human Immunodeficiency Virus

• The nurse is caring for a client infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which preventative measures will the nurse include in the plan of care? Select all that apply.