Question 1

Which line(s) of defense has been breached for this injury?

Accepted Answer

The first line of defense includes physical and chemical barriers like skin and mucous membranes, which prevent entry of pathogens. The second line of defense involves internal mechanisms like inflammation and fever. If an injury has occurred, it implies that the pathogens have bypassed the skin or mucous membranes (first line) and are now being combated by internal mechanisms (second line), indicating both first and second lines of defense have been breached.

Question 2

At this phase of injury, how would the nurse expect the area surrounding the laceration to present?

Accepted Answer

During the inflammatory phase of injury, increased blood flow to the area causes it to appear red and feel hot as the body brings in immune cells and nutrients to begin the healing process.

Question 3

The nurse examines the child's tonsils while preparing to swab them with the culture swab. A white pustule coating is noted to be covering the tonsils. What is this pus composed of?

Accepted Answer

The white pustule coating on the tonsils is most likely composed of white blood cells and debris from phagocytosis. This is a typical response of the immune system to battling infection caused by bacteria or viruses. Waste from red blood cells, live bacteria, and fibrin threads are not typically found in pus.

Question 4

Following teaching by the medical team, the patient asks "can I just do my airway clearance exercises when I am not feeling well and on the weekends, even though the doctor tells me I have to do them every day?" What is a correct response by the nurse?

Accepted Answer

Skipping airway clearance exercises can put the patient with compromised immunity at risk of pulmonary infections. It is important to maintain a daily routine of airway clearance exercises to help clear the lungs of mucus and prevent infection.

Question 5

What is the most likely cause of the patient's swollen tonsils?

Accepted Answer

Tonsils are part of the lymphatic system and play a role in filtering out microbes and their toxic products. Swollen tonsils may indicate an immune response to an infection in the body.

Question 6

The patient's mother expresses concern about her daughter's fevers. She states that the fevers are a sign that her child is unable to fight this infection. What is a proper response to these concerns?

Accepted Answer

Fevers are a natural response by the body to help fight infection. It is important to reassure the patient's mother that fevers are a common symptom of infections and the body's way of fighting off the illness.

Question 7

The patient asks why the laceration is puffy, and has become itchy. Which of the following statements by the nurse is the most appropriate response?

Accepted Answer

Option A is the correct answer because it accurately describes the body's normal response to injury. It provides a clear explanation of the cause of the patient's symptoms and reassures them that this is a normal part of the healing process. Options B, C, and D either provide inaccurate information or suggest inappropriate interventions.

Question 8

The patient asks the nurse to explain to him why he keeps getting sick from the same bacteria. Which of the following statements is the most appropriate response?

Accepted Answer

The mucus in the patient's respiratory system is responsible for trapping and harboring the microorganisms, which can then breach the second and third lines of defense. This is a common problem in patients with cystic fibrosis.

Question 9

What is the natural progression of healing for this wound?

Accepted Answer

The natural progression of wound healing typically involves a vascular reaction to injury, followed by the formation of edema/pus, and finally the development of a scar. Secondary injury can occur during the healing process, but it is not necessarily part of the natural progression. Exudative leaking is not a common stage in wound healing. Therefore, option D best represents the chronological progression of wound healing.

Question 10

The lab performs a complete blood count with cell differential while the patient is still in the office. The results show an elevated white blood cell count, as well as a high neutrophil count. What does this indicate?

Accepted Answer

An elevated white blood cell count and high neutrophil count are often indicative of a bacterial infection. Neutrophils are a type of white blood cell that are primarily responsible for fighting bacterial infections. Viral infections and parasitic infections, such as protozoan and helminth infections, may also cause an elevation in white blood cell count, but the differential may be different (e.g. lymphocytes may be increased in viral infections). Therefore, the best choice based on the given information is A, bacterial infection.

Question 11

The patient states, "There has to be a way for me to reduce this swelling. There is no way this can be good for me because it is so uncomfortable." Which of the following statements by the nurse is not an appropriate response?

Accepted Answer

The answer of The patient states, "There has to be...

Question 12

The nurse examines the child and finds that the lymph nodes along of her neck are warm, tender, and slightly enlarged. Her other lymph nodes are nonpalpable or small, nontender, rubbery, and less than 2 mm in size. What is the most accurate interpretation of this finding?

Accepted Answer

Warm, tender, and slightly enlarged lymph nodes in only one area of the body (in this case, the neck) are usually indicative of a localized infection in that area. The fact that the other lymph nodes are small, nontender, and non-enlarged also supports this interpretation. However, without further information, it is difficult to determine the specific cause or location of the infection.

Question 13

The patient asks the nurse to explain what cilia are. All of the following statements are correct except ________.

Accepted Answer

Cilia are not chemical-excreting natural killer cells, but rather tiny hair-like structures on the surface of certain cells that help move substances along or out of the body.

Quiz 12: Host Defenses I: Overview and Nonspecific Defenses