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Chapter 9- Inflammation, Tissue Repair, and Wound Healing
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1.
A 23-year-old man has received a recent diagnosis of appendicitis following 24 hours of acute abdominal pain. The nurse providing care for the man is explaining that while unpleasant, the inflammation of his appendix is playing a role in his body's fight against the underlying infectious process. Which of the following teaching points should the nurse eliminate from his teaching to the patient?
A)
?Inflammation can help to remove the body tissue cells that have been damaged by infection.?
B)
?Inflammation will start your body on the path to growing new, healthy tissue at the site of infection.?
C)
?Inflammation helps your body to produce the right antibodies to fight the infection.?
D)
?Inflammation ultimately aids in eliminating the initial cause of the cell injury in your appendix.?
Ans:
C
Feedback:
Antibody production is not a noted component of the inflammatory response. Removing damaged cells, generating new tissue, and eliminating the cause of cell injury are all documented components of the inflammatory response.
2.
A patient presented to the emergency department of the hospital with a swollen, reddened, painful leg wound and has been diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) cellulitis. The patient's physician has ordered a complete blood count and white cell differential. Which of the following blood components would the physician most likely anticipate to be elevated?
A)
Basophils
B)
Eosinophils
C)
Platelets
D)
Neutrophils
Ans:
D
Feedback:
Increased neutrophils are associated with inflammation in general and bacterial infections in particular. Platelets play a role in inflammation, but their levels would not rise to the same extent as would neutrophils'. Eosinophils are not strongly associated with bacterial infection, and basophils would not increase to the same degree as neutrophils.
3.
A 16-year-old girl has broken her arm while snowboarding. When she arrives at hospital, she is shocked at the amount of swelling at the injury site. Which of the following statements best explains the physiological rationale for her swelling?
A)
Migration and proliferation of mast cells, neutrophils, and platelets to the injury site occupy an increased volume of tissue.
B)
Potent vasodilation increases the total volume of vascular space at the site of inflammation.
C)
Osmotic flow of plasma into the intravascular space causes increased blood volume and interstitial fluid.
D)
Loss of plasma proteins causes an increase in interstitial osmotic pressure.
Ans:
D
Feedback:
Swelling is the result of plasma proteins leaving the interstitial space, resulting in increased osmotic pressure of interstitial fluid and movement of fluid into tissues. Blood components, vasodilation, nor increased intravascular volume accounts for swelling.
4.
Which of the following phenomena best accounts for the increased presence of leukocytes at the site of inflammation?
A)
Existing leukocytes stick to the epithelial cells and move along blood vessel walls.
B)
Increased numbers of leukocytes are released into circulation via cytokine stimulation.
C)
Leukocytes are osmotically drawn from circulation into the interstitial space as a result of swelling.
D)
Epithelium expresses leukocyte stimulation factors in response to cell injury.
Ans:
A
Feedback:
During inflammation, leukocytes accumulate at the point of epithelial contact in the processes of margination, adhesion, and transmigration. This is not directly achieved by a way of increased leukocyte production or release, nor by osmotic pressure. The epithelium does not produce leukocyte stimulation factors.
5.
When explaining the final stages of the inflammatory response to pathogens, the nurse will educate the patient about
A)
how the body can kill the pathogen by generating toxic oxygen and nitrogen products producing such things as nitric oxide and hydrogen peroxide.
B)
margination, which is a process whereby white cells (leukocytes) stick to the endothelium and accumulate along the blood vessel.
C)
the increase in vascular permeability, which lets fluids leak into the extravascular tissues.
D)
the promotion of tissue regeneration whereby monocytes and macrophages produce potent prostaglandins and leukotrienes.
Ans:
A
Feedback:
The latter stages of phagocytosis results in intracellular killing of pathogens accomplished by several mechanisms, including toxic oxygen and nitrogen products, lysozymes, proteases, and defensins. The metabolic burst pathways generate toxic oxygen and nitrogen products (i.e., nitric oxide, hydrogen peroxide, and hypochlorous acid). Margination is one of the early stages of the inflammatory response. Vascular changes occur with inflammation but are prior to the final stage. Macrophages arrive within hours at the inflammation site.
6.
A deficiency in which of the following would result in an inhibition of the inflammatory response?
A)
Histamine
B)
Helper T cells
C)
B cells
D)
Vitamin K
Ans:
A
Feedback:
Histamine is a key mediator in the inflammatory system, unlike helper T cells, B cells, or vitamin K.
7.
When educating a patient with a wound that is not healing, the nurse should stress which of the following dietary modifications to ward off some of the negative manifestations that can occur with inflammation?
A)
Increase the amount of calcium in the diet, especially drinking milk and eating cheese.
B)
This is the one time whereby you should eat more fat (both polyunsaturated and saturated), so you can absorb more fat soluble vitamins.
C)
Since there is a loss of plasma proteins, you should increase your intake of organ meats like liver.
D)
Increase your intake of oily fish and fish oil so that you will increase absorption of omega-3 polyunsaturated fatty acids.
Ans:
D
Feedback:
Dietary modification of the inflammatory response through the use of omega-3 polyunsaturated fatty acids, specifically eicosapentaenoic acid and docosahexaenoic acid, which are present in oily fish and fish oil, may be effective in preventing some negative manifestations of inflammation.
8.
Tumor necrosis factor-a and IL-1 are major cytokines that mediate inflammation. If the patient is developing a systemic response to an infection, the nurse will likely assess which of the following clinical manifestations? Select all that apply.
A)
Elevated temperature
B)
Hypertension
C)
Tachycardia
D)
Decrease in urine output
E)
Anorexia
Ans:
A, C, E
Feedback:
IL-1 and TNF-a are mediators of the acute-phase responses associated with infection or injury. Features of these systemic responses include fever (elevated temperature), hypotension, tachycardia (increased heart rate), anorexia, increase in neutrophil count, and increased levels of corticosteroid hormones.
9.
A 63-year-old woman has begun a diet that purports to minimize the quantity and effects of free radicals in her body. What physiological processes could best underlie her care provider's teaching about her new diet?
A)
Free radicals act as direct mediators in the inflammatory process.
B)
Free radicals inhibit the inflammatory response, limiting preadaptive response to infection.
C)
Free radicals increase cytokine expression and adhesion molecule levels, resulting in increased inflammation.
D)
Free radicals contribute to atherosclerosis and decreased immune response.
Ans:
C
Feedback:
Free radicals are thought to bring about an inappropriate inflammatory response by increasing cytokines and numbers of adhesion molecule. They are not direct mediators of inflammation and are not associated with decreased immune response but rather inappropriate inflammation. Free radicals are not associated with inhibition of the inflammatory response.
10.
A nurse is changing the wound dressing on the coccyx-region pressure ulcer of an immobilized patient. The existing dressing is saturated with both watery, clear discharge and foul, gray-colored liquid. Which of the following entries in the patient's chart best captures this?
A)
?Large amounts of suppurative and serous exudates noted?
B)
?Purulent discharge and fibrinous exudates noted on existing dressing?
C)
?Abscess activity noted to coccyx wound?
D)
?Plasma proteins and membranous exudates present on existing dressing?
Ans:
A
Feedback:
Serous discharge is clear and low in plasma proteins, while suppurative, or purulent, exudates are a mass of degraded cells. An abscess would be physically contained with no discharge, and the exudate is neither fibrinous nor membranous.
11.
Which of the following aspects of a patient's site of inflammation would help the care provider rule out chronic inflammation?
A)
High levels of macrophages
B)
Increased neutrophils
C)
Proliferation of fibroblasts
D)
Infiltration of lymphocytes
Ans:
B
Feedback:
Chronic inflammation lacks the sudden and marked proliferation of neutrophils that is associated with acute inflammation. Chronic inflammation is associated with increased presence and action of fibroblasts, macrophages, and lymphocytes.
12.
In the ICU, a patient has been diagnosed with sepsis due to a bacterial invasion. The human body usually responds to infections by developing an uncontrolled inflammatory response with large production and release of inflammatory cytokines such as IL-1 and TNF-a. The nurse will note which of the following clinical manifestations in this septic patient as a result of the activation of these cytokines? Select all that apply.
A)
Excessive interstitial edema related to increased vascular permeability
B)
Decreased cardiac output resulting from myocardial depression
C)
Increased respiratory rate with crackles heard throughout all lung fields
D)
Excessive bleeding from bowels and bladder
E)
Lower blood pressure due to intravascular fluid loss
Ans:
A, B, E
Feedback:
SIRS (systemic inflammatory response syndrome) can develop as a result of large quantities of microbes entering the blood, resulting in the release of enormous quantities of inflammatory cytokines. They cause generalized vasodilation (hypotension), increased vascular permeability (fluid loss into the tissues), intravascular fluid loss (dehydration with low urine output and low BP), myocardial depression (decreased cardiac output), and circulatory shock.
13.
A 24-year-old woman presents with fever and painful, swollen cervical lymph nodes. Her blood work indicates neutrophilia with a shift to the left. She most likely has
A)
a mild parasitic infection.
B)
a severe bacterial infection.
C)
a mild viral infection.
D)
a severe fungal infection.
Ans:
B
Feedback:
Fever and painful, palpable lymph nodes are nonspecific inflammatory conditions; leukocytosis is also common but is a particular hallmark of bacterial infection. Neutrophilia also indicates a bacterial infection, whereas increased levels of other leukocytes would indicate other etiologies. The shift to the left??the presence of many immature neutrophils??indicates that the infection is severe, because the demand for neutrophils exceeds the supply of mature cells.
14.
Which of the following patients would have a very poor response related to tissue regeneration of his or her injured area?
A)
A 21-day-old infant undergoing a diaphragmatic hernia repair
B)
A 54-year-old male who had a massive MI 4 days ago and came to the ED today for treatment
C)
A 73-year-old female who is undergoing lithotripsy for kidney stones
D)
A 33-year-old athlete undergoing surgery to repair a torn MCL in his right knee
Ans:
B
Feedback:
Permanent or fixed cells cannot undergo mitotic division. The fixed cells include nerve cells, skeletal muscle cells, and cardiac muscle cells.
15.
A hospital patient has a large, superficial wound on her elbow that was the result of shearing action when she was moved up in her bed. The patient's husband mentions that the wound looks infected and irritated because the wound bed is completely red. Which of the following responses would be inappropriate?
A)
?Even though it is red, it doesn't mean that the wound is infected.?
B)
?The red areas show that there is enough circulation to facilitate healing.?
C)
?Those are fresh blood vessels that are a sign of healthy healing.?
D)
?A thin sheet of blood clotting is actually desirable and not a sign that your wife's wound is infected.?
Ans:
D
Feedback:
Granulation tissue indicates sufficient circulation and angiogenesis associated with healthy wound healing. Granulation tissue consists of new blood vessels, not clotted cellular components.
16.
Which of the following processes would most likely be considered an anomaly during the cellular phase of inflammation?
A)
Platelet aggregation
B)
Vasoconstriction
C)
Migration of phagocytic white cells
D)
Macrophage activity
Ans:
B
Feedback:
While vasoconstriction is a component of the immediate inflammatory response, the later cellular phase of inflammation is accompanied by vasodilation. Platelet aggregation, vasoconstriction, migration of phagocytic white cells, and macrophage activity are all associated with the cellular phase.
17.
A patient who is recovering from burn injuries is discussing his prognosis with a physician. Which of the following teaching points about expectations for healing should the physician include?
A)
?Once your healing is complete, your skin will be just as strong as before your accident.?
B)
?You may find that the scar is a bit smaller than the area of the wound.?
C)
?You'll find that your new tissue is more elastic and fragile than the rest of your skin.?
D)
?The final remodeling phase of healing may last up to 3 months in your case.?
Ans:
B
Feedback:
Scars are often smaller than the original area of the wound. There is nearly always an accompanying loss of strength and elasticity, and remodeling can take over 6 months.
18.
Of the following list of patients, who would likely benefit the most from hyperbaric oxygen therapy?
A)
A trauma patient who developed Clostridium spp., an anaerobic bacterial infection in his femur
B)
A patient who developed a fistula between her bowel and vagina following cervical cancer surgery
C)
A school-aged child who fell on gravel and has terrible road rash
D)
A football player who has torn a meniscus in his knee for the third time this year
Ans:
A
Feedback:
Hyperbaric oxygen is a treatment that has demonstrated improved wound healing in multiple types of injuries. It enhances wound healing by a number of mechanisms, including the increased killing of bacteria by neutrophils, impaired growth of anaerobic bacteria, and the promotion of angiogenesis.
19.
Which of the following patients is most likely to have impairments to the wound-healing process? A patient with
A)
chronic obstructive pulmonary disease.
B)
a diagnosis of multiple sclerosis and consequent impaired mobility.
C)
poorly controlled blood sugars with small blood vessel disease.
D)
congenital heart defects and anemia.
Ans:
C
Feedback:
Diabetes mellitus is strongly associated with impaired wound healing. The other noted pathologies are less causative of deficiencies in the healing process.
20.
A 79-year-old female resident of an assisted living facility receives care from a community nurse on a regular basis for treatment of a chronic venous leg ulcer. Which of the following factors would the nurse be most justified in ruling out as a contributing factor to the client's impaired wound healing?
A)
A lower skin collagen content than in younger adults
B)
Decreased fibroblast synthesis
C)
Slow reepithelialization
D)
Decreased antibody levels
Ans:
D
Feedback:
Older adults do not normally have diminished antibody levels. Low collagen levels, decreased fibroblast activity, and slow reepithelialization are common impediments to wound healing in the elderly.
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