Blcok 2 Exam 5
What intervention is a priority when treating a patient with HIV /AIDS?
Assessing fluid and electrolyte balance
Which term means a lack of one or more of the five immunoglobulins?
Hypogammaglobulinemia
The nurse is caring for a young patient who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed?
"I can take my child to the beach, as long as we play in the sand rather than swim in the water." Explanation:
A nurse is explaining treatment options to a patient diagnosed with an immune dysfunction. Which of the following statements made by the patient accurately reflects the teaching about current stem cell research?
"Stem cell transplantation has been carried out in humans with certain types of immune dysfunction and clinical trials using stem cells are underway in patients with a variety of disorders having an autoimmune component."
A nurse is teaching the parents of an infant about primary immunodeficiencies. Which of the following statements verifies that the parents understand the teaching?
"The majority of primary immunodeficiencies are diagnosed in infancy." The majority of primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1
The nurse is obtaining an assessment and health history from the parents of a 6-month-old infant with an elevated temperature. Which statement by the parents will alert the nurse to a possible immunodeficiency disorder?
"This is the third infection with a high fever the baby has had in the past month."
Chronic mucocutaneous candidiasis is a rare T-cell disorder, which is thought to be an autosomal recessive disorder that affects both males and females
. In pedigrees, an autosomal recessive disorder is revealed by the appearance of the phenotype in the male and female progeny of unaffected individuals.
Fluid and electrolyte deficits are a priority in monitoring patients with HIV/AIDS. Assessment of fluid loss and electrolyte imbalance is essential. Skin integrity should be monitored, but is a lower priority.
. Neurologic and psychological status should also be monitored, but this is not as high a priority as fluid and electrolyte imbalance.
The p24 antigen is a blood test that measures viral core protein.
. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into a double-stranded DNA.
. In the effector stage, either the antibody of the humoral response or the cytotoxic T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader.
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Explanation: Renal failure is associated with a deficiency in circulating lymphocytes. Diabetes mellitus is associated with increased incidence of infection. Chemotherapy causes decreased bone marrow function. Leukemia is associated with altered production of white blood cells
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Infants with X-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins, which occurs at about 5 to 6 months of age. Symptoms of recurrent pyogenic infections usually occur by that time.
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Smoking causes an increased WBC count (indicating inflammation), elevated T cells (with decreased function), decreased antibody production (IgG, IgA, IgM), increased IgE (allergic response), and decreased natural killer (NK) cells (increased risk for infection) in the immune
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The nurse is teaching the patient with HIV about therapy. What is essential for the nurse to include in the teaching plan?
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. Parents must both be heterozygotes, C/c. (Both must have a c allele in order to contribute one to create a homozygote affected child with a cc phenotype displaying the disease.)
A child born with Cc will be phenotypically normal, but carry the recessive trait
A patient with common variable immunodeficiency (CVID) comes to the ED with complaints of tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes.
A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this patient developed?
A man with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks the nurse, "Will my children have this disease?" Which response by the nurse is appropriate?
All of your children will be carriers of the recessive gene but may not develop the disease."
Most immune responses to antigens involve both humoral and cellular responses, although one usually predominates. For example, during transplant rejection, the cellular response involving T cells predominates, in the bacterial pneumonias and sepsis, the humoral response involving B cells plays the dominant protective role.
Anaphylaxis is a humoral response role of B lymphocytes. Allergic hay fever and asthma are humoral response roles of B lymphocytes. Bacterial phagocytosis and lysis are humoral response roles of B lymphocytes.
A patient being treated for HIV/AIDS has a decreased appetite, almost to the point of anorexia. What is the nurse's best action?
Appetite stimulants are successfully used in patients with AIDS-related anorexia. The anorexia is compounded by medications that cause nausea and vomiting. The anorexia has a physiologic cause, and this must be addressed
Active acquired immunity refers to immunologic defenses developed by the person's own body. This immunity typically lasts many years or even a lifetime.
Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid. Passive immunity develops when ready-made antibodies are given to a susceptible individual.
Ataxia occurs with ataxia-telangiectasia. Episodes of edema in various body parts occur with angioneurotic edema.
Bacterial infection occurs with hyperimmunoglobulinemia E syndrome.
During a third-trimester transabdominal ultrasound, cardiac anomaly and facial abnormalities are noted on the fetus. Further testing reveals that the thymus gland has failed to develop normally and the fetus is diagnosed with thymic hypoplasia.
Based on this diagnosis, the nurse anticipates careful monitoring for which common manifestation during the first 24 hours of life? Hypocalcemia
Nezelof syndrome is a disorder involving lack of a thymus gland. Wiskott-Aldrich syndrome involves the absence of T cells and B cells and the presence of thrombocytopenia.
CVID is another term for hypogammaglobulinemia
A patient with paroxysmal hemoglobinuria, a deficiency of complement proteins, is complaining of headache and weakness of the right arm and leg. Based on these symptoms, for which health complication should the nurse assess with this patient?
Cerebral venous thrombosis Paroxysmal nocturnal hemoglobinuria is an acquired clonal stem cell disorder resulting from a somatic mutation in the hematopoietic stem cell
Which type of disorder produces recurrent and persistent infection of the soft tissue, lungs, and other organs? Primary phagocytic disorder
Chronic granulomatous disease, a type of primary phagocytic disorder, produces recurrent or persistent infections of the soft tissues, lungs, and other organs. The other deficiencies do not apply to recurrent and persistent infection of the soft tissue, lungs, and other organs
Nursing care must be meticulous. Appropriate infection control precautions and thorough hand hygiene are essential. Institutional policies and procedures related to protective care must be followed scrupulously until definitive evidence demonstrates that precautions are unnecessary.
Continual monitoring of the patient's condition is critical, so early signs of impending infection may be detected and treated before they seriously compromise the patient's status. It is imperative nurses appropriately apply standard precautions first line in disease prevention
A patient is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. He asks the nurse about the infusion's administration and its adverse effects. Which of the following choices should the nurse instruct this patient to report immediately? tickle in throat
Continually assess the patient for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction
Chronic illnesses may contribute to immune system impairment in various ways. Renal failure is associated?
Deficiency in circulating lymphocytes
Which blood test confirms the presence of antibodies to HIV? d) Enzyme-linked immunosorbent assay (ELISA)
ELISA, as well as Western blot assay, identifies and confirms the presence of antibodies to HIV. The ESR is an indicator of the presence of inflammation in the body
A nurse is caring for a patient undergoing evaluation for possible immune system disorders. Which of the following interventions will best help support the patient throughout the diagnostic process?
Educating the patient about the diagnostic procedures and answer questions they may have about the possible diagnosis
When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? Tightness in the chest
Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion. Nasal stuffiness and increased thirst are not recognized as adverse effects of gamma-globulin infusion.
"Breast-feeding is beneficial because the dominant antibody IgA in breast milk acts by functioning as an antigen receptor in the mucosal membranes."
IgA is 15% of total immunoglobulin. It appears in body fluids (blood, saliva, tears, breast milk, and pulmonary, gastrointestinal, prostatic, and vaginal secretions). It protects against respiratory, gastrointestinal, and genitourinary infections and passes to the neonate in breast milk for protection.
IgM appears as the first immunoglobulin produced in response to bacterial and viral infections.
IgD possibly influences B-lymphocyte differentiation
The patient is very concerned about the health of her unborn child. Based on the knowledge of the immune system, the delivery room nurse explains about which of the following immunoglobulins that will be increased in the fetus at he time of birth and actively fighting the infection?
IgG IgG is 75% of total immunoglobulin. It appears in serum and tissues, assumes a major role in bloodborne and tissue infections and crosses the placenta
Which of the following immunoglobulins assumes a major role in blood-borne and tissue infections? IgG
IgG assumes a major role in blood-borne and tissue infections. IgA protects against respiratory, GI, and genitourinary infections.
Parents should verbalize ways to plan for regular exercise and activity that does not pose a risk of infections.
Immunocompromised patients should avoid touching sand or soil because of the high level of bacteria and increased risk of diseases such as toxoplasmosis.
Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. Interferons have antiviral and antitumor properties.
In addition to responding to viral infection, interferons are produced by T lymphocytes, B lymphocytes, and macrophages in response to antigens. They are thought to modify the immune response by suppressing antibody production and cellular immunity.
Which type of phagocytic disorder occurs when white blood cells cannot initiate an inflammatory response to infectious organisms? hyperimmunoglobulinemia
In hyperimmunoglobulinemia, white blood cells cannot initiate an inflammatory response to an infectious organism.
A 6-year-old patient is diagnosed with a viral infection of the respiratory system. Which of the following will most likely be trying to fight the antigen?
Interferons
A 34-year-old man is diagnosed with chronic hepatitis C. Testing reveals that he is a candidate for treatment. The nurse anticipates that which of the following could be used to treat his condition? Interferons
Interferons are used to treat immune-related disorders (e.g., multiple sclerosis) and chronic inflammatory conditions (e.g., chronic hepatitis)
Pernicious anemia.More than 50% of patients with CVID develop pernicious anemia.
Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur.
Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and by releasing cytolytic enzymes and cytokines.
Lymphokines can recruit, activate, and regulate other lymphocytes and white blood cells (WBCs). These cells then assist in destroying the invading organism.
A major manifestation of Wiskott-Aldrich syndrome includes which of the following? Thrombocytopenia
Major symptoms of Wiskott-Aldrich syndrome include thrombocytopenia, infections, and malignancies
A patient seen in the outpatient clinic has common variable immunodeficiency. It is important for the nurse to teach the patient about the need for more frequent screening for which of the following complications?
Malignancy
A patient with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this patient?
Meticulous infection control precautions
A nurse is teaching a patient about the side effects of ibuprofen (Motrin). The patient's teaching is determined to be effective based on which of the following patient statements explaining the drugs effect on the immune system?
Motrin can cause neutropenia, which can increase my risk of infection." Motrin causes leukopenia and neutropenia
A 25-year-old man receives a knife wound to the leg in a hunting accident. Which of the following types of immunity was compromised? Natural Immunity
Natural immunity, which is nonspecific, provides a broad spectrum of defense against and resistance to infection. It is considered the first line of host defense following antigen exposure, because it protects the host without remembering prior contact with an infectious agent.
Which type of immunity becomes active as a result of the infection of a specific microorganism? Naturally acquired immunity
Naturally acquired active immunity occurs as a result of an infection of a specific microorganism.
A 20-year-old male patient cut his hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which of the following cell types to be elevated first in order to prevent an infection in the patient's hand?
Neutrophils Neutrophils (polymorphonuclear leukocytes [PMNs]) are the first cells to arrive at the site where inflammation occurs. Eosinophils and basophils, other types of granulocytes, increase in number during allergic reactions and stress responses.
Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes; therefore, the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early.
Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development
Which of the following nursing actions is essential before an EIA test is performed?
Obtaining a general consent for medical care from the patient. The Western blot test is performed if the results of the EIA test are positive.
Agammaglobulinemia is a disorder marked by an almost complete lack of immunoglobulins or antibodies
Panhypoglobulinemia is a general lack of immunoglobulins in the blood. Telangiectasias are vascular lesions caused by dilated blood vessels.
Hypogammaglobulinemia is a lack of one or more of the five immunoglobulins. Agammaglobulinemia is a disorder marked by an almost complete lack of immunoglobulins or antibodies.
Panhypoglobulinemia is a general lack of immunoglobulins in the blood. Telangiectasias are vascular lesions caused by dilated blood vessels.
A patient with common variable immunodeficiency disease (CVID) has an order for an IVIG infusion. What actions should the nurse perform prior to beginning the infusion?
Premedicate with acetaminophen and diphenhydramine. Assess for history of migraine headaches. Assess baseline vital signs. Obtain the patient's height and weight.
During which stage of the immune response does the circulating lymphocyte containing the antigenic message return to the nearest lymph node?
Proliferation Explanation: During the proliferation phase the circulating lymphocytes containing the antigenic message return to the nearest lymph node. Once in the node, these sensitized lymphocytes stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate.
The nurse teaches the patient that lowering his or her viral load will have what effect? A longer survival time
The lower the patient's viral load, the longer the survival time.
Continually assess the patient for adverse reactions; be especially aware of complaints of a tickle or lump in the throat as the precursor to laryngospasm that precedes bronchoconstriction.
Stop the infusions at the first sign of reaction and initiate the institutional protocol to be followed in this emergent situation.
hypocalcemia
The most frequent presenting sign in patients with thymic hypoplasia (DiGeorge syndrome) is hypocalcemia that is resistant to standard therapy. It usually occurs within the first 24 hours of life.
During an annual examination, an older patient tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel just fine!" Based on the knowledge of neoplastic disease and the aging immune system, what teaching should the nurse include in the patient's plan of care?
The increase in occurrence of autoimmune diseases due to aging strongly suggests a predisposition to various types of cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of finding and treating cancer early.
A nurse is reviewing the causes of genetic diseases with parents of an infant born with severe combined immunodeficiency disease (SCID). Which of the following would be inaccurate information pertaining to SCID
The inheritance of SCID can be autosomal dominant. Explanation: It is one of the most common causes of primary immunodeficiencies. Inheritance of this disorder can be X linked, autosomal recessive, or sporadic.
A nurse is assessing a patient with a primary immunodeficiency. Afterward she documents that the patient displayed ataxia. Which of the following statements explains the documentation?
The patient has uncoordinated muscle movements. Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination
The nurse is teaching the patient who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? I will be sure to eat lots of fresh fruits and vegetables every day."
The patient should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.
Advances in medical treatment have meant that patients with primary immunodeficiencies live longer, thus increasing their overall risk of developing cancer. Non-Hodgkin lymphomas account for most cancers.
The primary immunodeficiencies known to be associated with increased incidence of malignancy are common variable immunodeficiency, immunoglobulin A (IgA) deficiency, and deoxyribonucleic acid (DNA) repair disorders.
It is the nurse's role to counsel, educate, and support patients throughout the diagnostic process. Many patients may be extremely anxious about the results of diagnostic tests and the possible implications of those results for their employment, insurance, and personal relationships.
This is an ideal time for the nurse to provide counseling and education.
An infant is diagnosed with agammaglobulinemia. The nurse reviews the family history for a male relative with this disorder, which the nurse knows is also known by which of the following names? Burton Disease
This syndrome is called X-linked agammaglobulinemia (Bruton's disease). Bruton's disease is a sex-linked disease that results in infants born with the disorder suffering severe infections soon after birth.
Which of the following responses identifies a role of T lymphocytes?
Transplant rejections
Which of the following statements reflects the treatment of HIV infection?
Treatment of HIV infection for an individual patient is based on the clinical condition of the patient, CD4 T cell count level, and HIV RNA (viral load).
Although specific therapies vary, treatment of HIV infection for an individual patient is based on three factors: the clinical condition of the patient, CD4 T cell count level, and HIV RNA or viral load.
Treatment should be offered to all patients with the primary infection acute HIV syndrome. In general, treatment should be offered to individuals with fewer than 350 CD4+ T cells/mm or plasma HIV RNA levels exceeding 55,000 copies/mL RT-PCR assay.
A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which of the following statements?
We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen (HLA)-identical sibling."
An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis.
Which cells should be isolated? Cytotoxic T Cells
Secondary immunodeficiencies occur as a result of underlying disease processes or the treatment of these disorders, including administration of immunosuppressive agents. Abnormalities of the immune system affect both natural and acquired immunity. Because immunodeficiencies result in
a compromised immune system and pose a high risk for infection, careful assessment of the patient's immune status is essential. The nurse assesses and monitors the patient for signs and symptoms of infection.
Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A (IgA), a type of antibody that protects against infections of the lining the mouth and digestive tract." Selective immunoglobulin A deficiency is congenital
and characterized by a lack of immunoglobulin A, which predisposes patients to recurrent infections, adverse reactions to blood transfusions or immunoglobulin, autoimmune diseases, and hypothyroidism. There is no current treatment.
. Clinical manifestations may be indolent or life threatening. The disorder is characterized by hemoglobinuria that increases during sleep,
as well as intravascular hemolysis, cytopenia, infections, bone marrow hyperplasia, and a high incidence of life-threatening venous thrombosis, which occurs most commonly in the abdominal and cerebral veins.
A nurse is developing a teaching plan for a community presentation on smoking cessation. Based on current research regarding the effects of cigarette smoking on the immune system, which of the following alterations in
immune function can be attributed to smoking and should be included in the teaching presentation? Decreased natural killer (NK) cells Decreased T cell function Increased white blood cell (WBC) count Increased risk of infection
Thirty minutes after the nurse begins an intravenous immunoglobulin (IVIG) infusion, the patient complains of itching at the site and a lump in the throat. Which is the first action the nurse should take?
stop the infusion
Treatment options for SCID include stem cell and bone marrow transplantation. HSCT is the definitive therapy for SCID;
the best outcome is achieved if the disease is recognized and treated early in life. The ideal donor is a human leukocyte antigen HLA identical sibling
A patient comes into the emergency department with complaints of difficulty walking and loss of muscle control in the arms. As the nurse begins the physical examination,
which of the following assessment should be completed if an immune dysfunction in the neurosensory system is suspected?Assess for ataxia using the finger-to-nose test and heel-to-shin test Ataxia should be assessed when suspecting immune dysfunction in the neurosensory system
In the proliferation stage, the circulating lymphocyte containing the antigenic message returns to the nearest lymph node.
In the effector stage, either the antibody of the humoral response of the cytotoxic TA cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader.
. In the recognition stage, the immune system distinguishes an invader as foreign, or non-self.
In the response stage, the changed lymphocytes function either in a humoral or cellular fashion.
Which stage of the immune response occurs when the differentiated lymphocytes function in either a humoral or a cellular capacity? Response stage
In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. Recognition of antigens as foreign or nonself, by the immune system is the initiating event in any immune response.
Infants with DiGeorge syndrome have which type of endocrine disorder? Hypoparathyroidism
Infants born with DiGeorge syndrome have hypoparathyroidism with resultant hypocalcemia resistant to standard therapy. The other endocrine disorders do not occur in DiGeorge syndrome
The exact incidence of SCID is unknown; it is recognized as a rare disease in most population groups, with an incidence of about 1 case in 1,000,000. This illness occurs in all racial groups and both genders.
The nurse is working with a mother whose child has just been diagnosed with selective immunoglobulin A deficiency. will the child die?
What intervention is appropriate before the patient starts on efavirenz-EFV, Sustiva therapy? Testing for Stevens-Johnson syndrome potential
A patient should be tested for the gene for Stevens-Johnson syndrome prior to receiving any drugs that potentially can cause this condition. The patient does not have to receive Benadryl or have renal function tests. There are no particular foods that should be restricted.
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
A polymerase chain reaction test, which measures viral loads, is used if diagnosis is confirmed as positive.
Variables affecting the risk and intensity of adverse events associated with the administration of IVIG include patient age, underlying condition, history of migraine, and cardiovascular and/or renal disease; dose, concentration, and rate of infusion
The nurse must assess all of these variables before starting the IVIG infusion: obtain height and weight before treatment to verify accurate dosing; assess baseline vital signs before, during, and after treatment; premedicate with acetaminophen and diphenhydramine as prescribed 30 minutes before the start of the infusion.
