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 C

Explanation

A. Consume foods high in potassium: Potassium deficiency can contribute to certain health issues, but it is not directly linked to hearing loss. However, maintaining a balanced diet rich in nutrients, including potassium, is important for overall health.

B. Increase oral intake of water: Hydration is essential for overall health, but increasing oral intake of water is not specifically associated with decreasing the risk of hearing loss. While staying hydrated is beneficial for various bodily functions, including maintaining proper ear function, it is not a direct preventive measure for hearing loss.

C. Avoid smoking tobacco products: Smoking tobacco products is a significant risk factor for developing hearing loss. Smoking can damage blood vessels and reduce blood flow to the inner ear, leading to hearing impairment. Therefore, advising clients to avoid smoking or quit smoking is an important lifestyle modification to decrease the risk of hearing loss.

D. Limit alcohol to two drinks daily: Excessive alcohol consumption can have detrimental effects on hearing health, including increasing the risk of hearing loss and vestibular dysfunction. Therefore, limiting alcohol intake is recommended to reduce the risk of developing hearing-related problems.

A. "I'm glad that I can work remotely from my computer." B. "l can't wait to be able to take a bath." C. "l get bored only being able to watch television." D. "l will be relieved once I can drive myself to the store." E. None F. None

Correct Answer is C

Explanation

Answer: C

Rationale:

A) "I'm glad that I can work remotely from my computer. Prolonged use of a computer can strain the eyes, potentially interfering with the healing process after a retinal reattachment procedure. Clients are generally advised to limit screen time during recovery.

B) "I can't wait to be able to take a bath. Submerging the face in water, as during a bath, is discouraged postoperatively due to the risk of introducing bacteria into the eye and delaying healing. Clients are advised to stick to showers and avoid getting the affected eye wet.

C) "I get bored only being able to watch television. Watching television is usually permissible following retinal surgery, as it does not strain the eye excessively. This statement aligns with typical postoperative instructions.

D) "I will be relieved once I can drive myself to the store." Driving is contraindicated during the recovery phase due to potential visual disturbances and the need for the eye to heal properly. Clients are typically instructed to avoid driving until cleared by their ophthalmologist.

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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?

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