A nurse is teaching a class about the steps of the inflammatory response. The nurse should include that which of the following is the first step in the inflammatory response?
Inflammatory cells are activated
Release of inflammatory markers, such as C-reactive protein
Inflammatory pathways are triggered
Recognition of harmful stimuli by patern receptors on cell surfaces
The Correct Answer is D
The first step in the inflammatory response is the recognition of harmful stimuli by pattern recognition receptors (PRRs) on the surfaces of various cells, including immune cells and non-immune cells. PRRs recognize specific patterns associated with pathogens, damage-associated molecular patterns (DAMPs), and pathogen-associated molecular patterns (PAMPs), among others. This recognition leads to the activation of signaling pathways that promote the recruitment and activation of immune cells and the release of inflammatory mediators, such as cytokines and chemokines.
Once the PRRs recognize the harmful stimuli, inflammatory cells are activated, including neutrophils, macrophages, and dendritic cells. These cells then release inflammatory markers, such as C-reactive protein, which promote the recruitment and activation of more immune cells and further amplify the inflammatory response. Inflammatory pathways are also triggered, leading to the production of various inflammatory mediators and the activation of transcription factors that regulate the expression of genes involved in the inflammatory response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.
B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.
C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.
D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.
Correct Answer is B
Explanation
Answer: B. A client who is unconscious.
A. A client who has a spinal cord injury.
While a spinal cord injury is serious and requires close monitoring, this condition does not immediately indicate that the client is unstable or at risk for life-threatening complications compared to an unconscious client. However, if there were signs of respiratory compromise or neurogenic shock, this client could be prioritized higher.
B. A client who is unconscious.
An unconscious client should be seen first because their condition may indicate a critical issue such as impaired airway, breathing, or circulation (ABC). Immediate assessment is needed to ensure the airway is clear, breathing is adequate, and circulation is stable, as these are life-threatening concerns.
C. A client who has peripheral vascular disease.
Clients with peripheral vascular disease (PVD) typically have chronic issues related to circulation in the limbs, which can cause pain and discomfort but are not usually immediately life-threatening. While important, this client is not the top priority compared to an unconscious client.
D. A client who has a new ankle sprain.
A new ankle sprain is painful and requires treatment, but it is not life-threatening. The nurse should address this client after ensuring the more urgent needs of other clients are met, such as the unconscious client who may require immediate interventions to preserve life.
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