After assessing a patient who underwent a transurethral resection of the prostate, the nurse assesses a temperature of 96.8°F, a respiratory rate of 26, and a white blood cell (WBC) count of 3,000 mm3
The nurse recognizes the patient's pathophysiological process is due to 1. homeostasis.
2. localized inflammation.
3. multiple organ dysfunction syndrome.
4. systemic inflammatory response syndrome.
4
Rationale: Systemic inflammatory response syndrome is correct because the clinical manifestations include a respiratory rate of greater than 20 breaths per minute and a white blood cell count below 4,000/mm3. Homeostasis is incorrect because the clinical manifestations are not compatible with a state of equilibrium found in homeostasis. Localized inflammation is incorrect because localized inflammation's hallmark responses are redness, heat, swelling, pain, and loss of function of a body part. Multiple organ dysfunction syndrome is incorrect because in this syndrome, two or more organ systems are affected and it develops after acute life-threatening disruption of systemic body homeostasis.
You might also like to view...
When assessing a client's lateral flexion of the cervical spine, the nurse asks the client to:
A) look at the ceiling. B) touch the chin to the chest. C) turn the head and look to the left. D) touch the ear to the shoulder.
A nurse is writing a care plan for a client hospitalized with lung cancer. Her priority nursing diagnosis is ineffective airway clearance. Which intervention should the nurse include?
1. Administration of the pneumococcal vaccine 2. Smoking cessation education 3. Limit fluid intake 4. Chest percussion
Which was the first state to pass a law licensing practical nurses?
a. Alabama b. California c. New York d. Mississippi
A patient with tachycardia, an abnormally rapid heartbeat, is experiencing:
A. sympathetic activation. B. sympathetic inhibition. C. parasympathetic activation. D. parasympathetic inhibition.