A nurse is explaining the pathophysiology of systemic inflammatory response syndrome (SIRS) to a group of newly licensed nurses. Which of the following statements by the nurse is accurate?

"A deregulated cytokine storm causes an inflammatory response."

"The major organ prone to injury during SIRS is the heart."

"Spleen dysfunction causes blood clotting issues."

"Activation of the inflammatory cascade causes increased perfusion."

Answer and Explanation

The Correct Answer is A

A. "A deregulated cytokine storm causes an inflammatory response": Systemic inflammatory response syndrome (SIRS) is characterized by a dysregulated inflammatory response triggered by various insults such as infection, trauma, burns, or ischemia. In SIRS, the immune system responds excessively, leading to the release of pro-inflammatory cytokines (cytokine storm), including tumor necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and interleukin-6 (IL-6). This cytokine cascade results in widespread inflammation and systemic manifestations, such as fever, tachycardia, tachypnea, and leukocytosis.

B. "The major organ prone to injury during SIRS is the heart": While SIRS can lead to multi-organ dysfunction, including cardiac dysfunction, it does not primarily target the heart. SIRS affects multiple organs, including the lungs, kidneys, liver, and gastrointestinal tract. Cardiac dysfunction in SIRS may result from the inflammatory response, hypoperfusion, or direct myocardial injury.

C. "Spleen dysfunction causes blood clotting issues": SIRS can lead to coagulation abnormalities, but spleen dysfunction is not the primary cause. Coagulation abnormalities in SIRS are often attributed to endothelial dysfunction, activation of the coagulation cascade, and consumption of clotting factors, rather than spleen dysfunction.

D. "Activation of the inflammatory cascade causes increased perfusion": Activation of the inflammatory cascade in SIRS does not typically lead to increased perfusion. Instead, SIRS can lead to alterations in perfusion, including tissue hypoperfusion and microvascular dysfunction. In severe cases, SIRS can progress to septic shock, characterized by profound hypotension and inadequate tissue perfusion.

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Correct Answer is B

Explanation

A. Persistent headache and aggression: While persistent headache and aggression can occur following a traumatic brain injury (TBI), these symptoms are not specific to mild TBI. Aggression is more commonly associated with severe TBI, and persistent headache can occur across the spectrum of TBI severity.

B. Headache and confusion: Headache and confusion are common manifestations of mild TBI. Following a mild TBI, individuals often experience headache, which may be mild to moderate in intensity. Confusion, disorientation, and difficulty concentrating are also typical symptoms of mild TBI due to the transient disruption of cognitive function.

C. Loss of vision and depression: Loss of vision and depression are less commonly associated with mild TBI. These manifestations may occur in more severe cases of TBI or with specific types of brain injury affecting visual pathways. However, they are not typically indicative of mild TBI.

D. Seizures and extremity weakness: Seizures and extremity weakness are more indicative of moderate to severe TBI rather than mild TBI. While mild TBI may result in brief loss of consciousness, seizures and significant extremity weakness are less characteristic of mild TBI and are more commonly observed with more severe brain injuries.

A. Intermittent pneumatic compression pumps B. Ankle-brachial index test C. Layered wraps D. Elevation of legs E. Exercise

Correct Answer is ["A","C","D","E"]

Explanation

A. Intermittent pneumatic compression pumps: Intermittent pneumatic compression pumps can help improve circulation in the lower extremities by assisting with venous return. These devices inflate and deflate sequentially, promoting venous blood flow and reducing edema in clients with peripheral venous disease.

B. Ankle-brachial index test: The ankle-brachial index (ABI) test is a non-invasive vascular study used to assess peripheral arterial disease (PAD). It compares the blood pressure in the ankle with the blood pressure in the arm to evaluate arterial circulation.

C. Layered wraps: Layered wraps, such as compression bandages or stockings, are typically used in the management of venous insufficiency and venous ulcers. They are not as commonly utilized in peripheral venous disease, however, they may be beneficial for some clients with PVD.

D. Elevation of legs: Elevating the legs above the level of the heart can help reduce edema and improve venous return in clients with peripheral venous disease. Gravity assists in draining blood from the lower extremities back toward the heart, thereby reducing swelling and discomfort.

E. Exercise: Regular physical activity, particularly lower extremity exercises such as walking, can promote venous return and improve circulation in clients with peripheral venous disease. Exercise helps to pump blood back to the heart, reducing venous stasis and the risk of complications such as venous thrombosis.

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A nurse is explaining the pathophysiology of systemic inflammatory response syndrome (SIRS) to a group of newly licensed nurses. Which of the following statements by the nurse is accurate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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