adult health- immune system

A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? 1. Western blot 2 CD4+ cell count 3. Enzyme-linked immunosorbent assay (ELISA) 4. Complete blood cell (CBC) count with differential

CD4+ cell count

The nursing student enrolled in an anatomy and physiology course is studying the immune system. The nursing instructor determines that the student understands the chemical barriers against a nonspecific immune response if which statement is made? 1. "The skin is considered a chemical barrier." 2. "The mucous membranes act as chemical barriers." 3. "The cilia lining the respiratory tract are chemical barriers." 4. "Acids and enzymes found in body fluids function as chemical barriers."

"Acids and enzymes found in body fluids function as chemical barriers." Chemical barriers include various acids and enzymes found in body fluids. The skin, the mucous membranes, and the action of cilia lining the respiratory tract are physical barriers.

The nurse instructs a client with candidiasis (thrush) of the oral cavity on how to care for the disorder. Which client statement indicates the need for further instruction? 1. "I need to eat foods that are liquid or pureed." 2. "I need to eliminate spicy foods from my diet." 3. "I need to eliminate citrus juices and hot liquids from my diet." 4. "I need to rinse my mouth 4 times daily with a commercial mouthwash."

"I need to rinse my mouth 4 times daily with a commercial mouthwash." Candidiasis is caused by Candida albicans, which is a part of the intestinal tract's natural flora. Fungal infection occurs by overgrowth of normal body flora. Candida stomatitis or esophagitis occurs often in in immunocompromised clients. On examination of the mouth and throat, the nurse would note cottage cheese-like, yellowish white plaques and inflammation. Clients with candidiasis cannot tolerate commercial mouthwashes because the high alcohol concentration in these products can cause pain and discomfort to the lesions. A solution of warm water or mouthwash formulas without alcohol are better tolerated and may promote healing. A change in diet to liquid or pureed food often eases the discomfort of eating. The client should avoid spicy foods, citrus juice, and hot liquids.

The nurse is assisting in administering immunizations as well as providing education to the clients who receive them at a health care clinic. Which statement by a client indicates that teaching was successful? 1 "Immunizations protect against all diseases." 2. "Immunizations can provide natural immunity." 3. "Immunizations can provide innate immunity." 4. "Immunizations are a way to acquire immunity to a specific disease."

"Immunizations are a way to acquire immunity to a specific disease."

The nursing student is reviewing information related to the primary purpose of neutrophils in the inflammatory response. The nursing instructor determines that understanding is accurate when which statement is made by the student? 1. "Neutrophils dilate the blood vessels." 2. "Neutrophils increase fluids at the site of injury." 3. "Neutrophils allow permeability of the blood vessels." 4. "Neutrophils phagocytize any potentially harmful agents."

"Neutrophils phagocytize any potentially harmful agents."

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an altered immune system and the role of interferons is discussed. Which statement by the nursing student indicates a need for further teaching? 1. "They are produced by several types of cells." 2. "They are effective against a wide variety of viruses." 3. "They are effective against a wide variety of bacteria." 4. "They have been effective to some degree in the treatment of melanoma."

"They are effective against a wide variety of bacteria." Interferon is produced by several types of cells and is effective against a wide variety of viruses (not bacteria). It works on the host cells to induce protection and differs from an antibody, which inactivates viruses found outside the cells. Interferons have been effective to some degree in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma.

A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? 1. No further diagnostic studies are needed. 2 A Western blot will be done to confirm these findings. 3. The client probably will have a bone marrow biopsy done. 4. A CD4+ cell count will be done to measure T helper lymphocytes.

A Western blot will be done to confirm these findings. Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. If the result of the ELISA is positive, the Western blot is done to confirm the findings. If the result of the Western blot is positive, the client is considered to be seropositive for the infection and to be infected with the virus. The remaining options are incorrect.

The clinic nurse reads the chart of a client just seen by the health care provider (HCP) and notes that the HCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client? 1. Generalized skin rash 2. Cardiac dysrhythmia 3. Complaints of joint pain 4. Paralysis of the affected extremity

Complaints of joint pain Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgias and enlargement or inflammation of joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage II. A rash occurs in stage I. Paralysis of the extremity on which the bite occurred is not a characteristic of Lyme disease.

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? 1. Determines the presence of antigens 2. Identifies which additional tests need to be performed 3. Confirms the diagnosis of a connective tissue disorder 4. Confirms the presence of inflammation or infection in the body

Confirms the presence of inflammation or infection in the body The ESR is a blood test that can confirm the presence of inflammation or infection in the body. It is particularly useful for the management of connective tissue disease because the rate measured directly correlates with the degree of inflammation and later with the severity of the disease. The other options are incorrect.

A home care nurse is prescribing dressing supplies for a client who has an allergy to latex. Which item should the nurse ask the medical supply personnel to deliver? 1. Elastic bandages 2. Adhesive bandages 3. Brown Ace bandages 4. Cotton pads and silk tape

Cotton pads and silk tape

The nurse has been assigned to care for a client with an immune disorder. In developing a plan of care for this client, the nurse incorporates knowledge that the immune system consists of specific major types of cells. Which types of cells are associated with the immune system? Select all that apply. 1 Dendritic cells 2. B lymphocytes 3. Red blood cells 4. Helper T lymphocytes 5. Cytolytic T lymphocytes

Dendritic cells B lymphocytes Helper T lymphocytes Cytolytic T lymphocytes Immunity is composed of many cell functions that protect against the effects of injury or invasion. The immune system has 5 major types of cells: dendritic cells, B lymphocytes or B cells, helper T lymphocytes or CD4+ cells, cytolytic T lymphocytes or CD8+ cells, and macrophages.

The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested for human immunodeficiency virus (HIV)? Select all that apply. 1. Injection drug abusers 2. Prostitutes and their clients 3. People with sexually transmitted infections (STIs) 4. People who have had frequent episodes of pneumonia 5. People who recently received a blood transfusion for a surgical procedure

Injection drug abusers Prostitutes and their clients People with sexually transmitted infections (STIs)

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. 1. Keep liquids at the bedside. 2. Place a towel over the pillowcase. 3. Make sure the pillow has a plastic cover. 4. Keep a change of bed linens nearby in case they are needed. 5. Administer an antipyretic after the client has a spike in temperature.

Keep liquids at the bedside. Place a towel over the pillowcase. Make sure the pillow has a plastic cover. Keep a change of bed linens nearby in case they are needed. Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at the bedside to drink.

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE? 1. Fever 2. Fatigue 3. Skin lesions 4. Elevated red blood cell count

Skin lesions

A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result should the nurse anticipate? 1. The presence of inflammation 2. The presence of infection in the body 3. The presence of antigens of immunoglobulin A (IgA) 4. The presence of unusual antibodies of the IgG and IgM types

The presence of unusual antibodies of the IgG and IgM types Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The rheumatoid factor assay tests for the presence of unusual antibodies of the IgG and IgM types, which develop in a number of connective tissue diseases. The test result in a person without RA would be negative or <60 units/mL by nephelometric method of laboratory testing. The other options are incorrect.

The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity? 1. Sunlight 2. Going to parties 3. The use of latex condoms 4. Outdoor activities as much as possible

The use of latex condoms duh

The nurse reviews the record of a client with acquired immunodeficiency syndrome (AIDS) and notes that the client has a diagnosis of Candida. When performing history-taking and assessment, which finding should the nurse anticipate? 1. Hyperactive bowel sounds 2. Complaints of watery diarrhea 3. Red lesions on the upper arms 4. Yellowish-white, curdlike patches in the oral cavity

Yellowish-white, curdlike patches in the oral cavity

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

bananas

A client is admitted to the hospital with a diagnosis of parasitic worms. By reviewing the client's complete blood cell (CBC) count results, which cells indicate attack by these foreign bodies? 1. Basophils 2. Neutrophils 3. Eosinophils 4. Dendritic cells

eosinophils

A nursing instructor is reviewing information on the organs of the immune system. The instructor asks a nursing student to name the location of Kupffer cells. Which organ identified by the nursing student indicates successful teaching? 1. The liver 2. The spleen 3. The tonsils 4. Bone marrow

the liver