CH 31: Assessment of Immune Function
In which process is the antigen-antibody molecule coated with a sticky substance that facilitates phagocytosis? A) Opsonization B) Immunoregulation C) Agglutination D) Apoptosis
A) Opsonization Explanation: In the process of opsonization, the antigen-antibody molecule is coated with a sticky substance that facilitates phagocytosis. Apoptosis is programmed cell death that results from the digestion of DNA by endonucleases. Agglutination is the clumping effect that occurs when an antibody acts as a cross-link between two antigens. Immunoregulation is a complex system of checks and balances that regulates or controls immune responses.
A client requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this client most likely has which type of immune disorder? A. A primary immune deficiency B. A gammopathy C. An autoimmune disorder D. A rheumatic disorder
A. A primary immune deficiency Explanation: Primary immune deficiency results from improper development of immune cells or tissues. These disorders are usually congenital or inherited. Autoimmune disorders are less likely to have a genetic component, though some have a genetic component. Overproduction of immunoglobulins is the hallmark of gammopathies. Rheumatic disorders do not normally involve impaired immune function.
An infection control nurse is presenting an in-service reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining? A. Agglutination B. Cellular immune response C. Humoral response D. Phagocytic immune response
A. Agglutination Explanation: Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link between two antigens. This takes place within the context of the humoral immune response, but is not synonymous with it. Cellular immune response, the immune system's third line of defense, involves the attack of pathogens by T-cells. The phagocytic immune response, or immune response, is the system's first line of defense, involving white blood cells that have the ability to ingest foreign particles.
A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization, which will allow for the release of which type of substance? A. Antibodies B. Antigens C. Cytokines D. Phagocytes
A. Antibodies Explanation: Immunizations activate the humoral immune response, culminating in antibody production. Antigens are the substances that induce the production of antibodies. Cytokines are nonantibody proteins secreted by helper T cells that act as intercellular mediators, as in the generation of immune response. They attract and activate B cells, cytotoxic T cells, natural killer cells, macrophages, and other cells of the immune system. Phagocytes are white blood cells that engulf, ingest, and destroy foreign bodies or toxins. Immunizations do not prompt cytokine or phagocyte production.
A client has undergone treatment for urosepsis and received high doses of numerous antibiotics during the course of treatment. When planning the client's subsequent care, the nurse should be aware of which potential effect on the client's immune function? A. Bone marrow suppression B. Uncontrolled apoptosis C. Prostaglandin synthesis inhibition D. Immunosuppression
A. Bone marrow suppression Explanation: Large doses of antibiotics can precipitate bone marrow suppression, affecting immune function. Uncontrolled apoptosis, or programmed cell death, is not known to be an effect of antibiotic therapy. Inhibition of prostaglandin synthesis or release can be an effect of nonsteroidal anti-inflammatory drugs but is not typically an effect of antibiotic therapy. Immunosuppression can be an effect of adrenal corticosteroids, antineoplastic agents, and antimetabolites, but is not typically an effect of antibiotic therapy.
A client is vigilant in self-care but is frustrated by a recent history of upper respiratory infections and influenza. Which aspects of the client's lifestyle may have a negative effect on immune response? Select all that apply. A. Exercises at the gym twice a day B. Does not consume any red meat C. Takes over-the-counter daily vitamins D. Sleeps approximately seven hours daily E. Works as a medical researcher
A. Exercises at the gym twice a day E. Works as a medical researcher Explanation: Rigorous or competitive exercise—usually considered a positive lifestyle factor—can be a physiologic stressor and cause negative effects on immune response. Occupational or residential exposure to environmental radiation and pollutants has been associated with impaired immune function. Research jobs are among those with a higher risk of workplace pollution. Taking a multivitamin daily and not eating red meat are generally positive steps as long as the client does not rely solely on the vitamin to provide all nutrients and has the appropriate level of protein intake. Seven to nine hours of sleep daily are the general recommendations for good health and an effective immune system.
A client's exposure to which microorganism is most likely to trigger a cellular response? A. Herpes simplex B. Staphylococcus aureus C. Pseudomonas aeruginosa D. Beta-hemolytic Streptococcus
A. Herpes simplex Explanation: Viral, rather than bacterial, antigens induce a cellular response. Herpes simplex is a virus. Staphylococcus aureus, Pseudomonas aeruginosa, and beta-hemolytic Streptococcus are all bacteria.
A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which complication of therapy? A. Immunosuppression B. Agranulocytosis C. Anemia D. Thrombocytopenia
A. Immunosuppression Explanation: Corticosteroids, such as prednisone, can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts. Agranulocytosis, which is a decrease in granulocytes, a type of white blood cell, may be caused by antibiotics, antithyroid drugs, or nonsteroidal anti-inflammatory drugs. Anemia, which is a decrease in red blood cells, may be caused by antibiotics or nonsteroidal anti-inflammatory drugs. Thrombocytopenia, which is a decrease in platelets, may be caused by antibiotics.
The nurse is providing care for a client who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment? A. Stem cell transplantation B. Serial immunizations C. Immunosuppression D. Genetic engineering
A. Stem cell transplantation Explanation: Clinical trials using stem cells are underway in clients with a variety of disorders having an autoimmune component, including multiple sclerosis. Immunizations and genetic engineering are not used to treat multiple sclerosis. Immunosuppression would exacerbate symptoms of MS.
During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses: A. acquired immunity. B. natural immunity. C. phagocytic immunity. D. humoral immunity.
A. acquired immunity. Explanation: Acquired immunity usually develops as a result of prior exposure to an antigen, often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three means of defense. The first line of defense, the phagocytic immune response, involves the WBCs that have the ability to ingest foreign particles. A second protective response is the humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells that manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present at birth.
A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of: A. lymphocytes. B. cytoblasts. C. antibodies. D. capillaries.
A. lymphocytes Explanation: The white blood cells involved in immunity (including lymphocytes) are produced in the bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels.
What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction? A) IgA B) IgE C) IgM D) IgG
B) IgE Explanation: IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reactions. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.
The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response? A) The invading antigens link together (agglutination). B) T-cell lymphocytes survey proteins in the body and attack the invading antigens. C) Toxins of invading antigens are neutralized. D) The invading antigens precipitate.
B) T-cell lymphocytes survey proteins in the body and attack the invading antigens. Explanation: During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their toxins through agglutination or by causing them to precipitate.
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include: A) regulator T cells and helper T cells. B) neutrophils and monocytes. C) lymphokines and suppressor T cells. D) plasma cells and memory cells.
B) neutrophils and monocytes. Explanation: Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.
A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process? A. The cellular immune response B. Apoptosis C. Phagocytosis D. Opsonization
B. Apoptosis Explanation: Apoptosis, or programmed cell death, is the body's way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Opsonization is the coating of antigen-antibody molecules with a sticky substance to facilitate phagocytosis. The body does not use phagocytosis or the cellular immune response to remove cells from circulation.
A client is undergoing testing to determine the overall function of the client's immune system. Which test will best identify the functioning of the client's cellular immune system? A. Immunoglobulin testing B. Delayed hypersensitivity skin test C. Specific antibody response D. Total serum globulin assessment
B. Delayed hypersensitivity skin test Explanation: Cellular (cell-mediated) immunity tests include the delayed hypersensitivity skin test, since this immune response is specifically dependent on the cellular immune response. Each of the other listed tests assesses functioning of the humoral immune system.
A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will cause the client to develop which expected and desired condition? A. Natural immunity B. Passive acquired immunity C. Cellular immunity D. Mild hypersensitivity
B. Passive acquired immunity Explanation: Passive/adaptive acquired immunity usually develops as a result of vaccination or contracting a disease. Natural immunity is present at birth and provides a nonspecific response to any foreign invader. Immunizations do not activate the process of cellular immunity. Cellular immunity is part of the innate/natural immunity response, which involves T cells that neutralize components of the threat within the cell itself. Hypersensitivity is infrequent, and adverse reactions (i.e., urticaria, anaphylaxis) to vaccine administration are rare.
A client has been brought to the emergency department by the parents after falling through the glass of a patio door, sustaining a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of which type of cell? A. Interferons B. Phagocytic cells C. Helper T cells D. Cytokines
B. Phagocytic cells Explanation: Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken glass. 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. Helper T cells are activated on recognition of antigens and stimulate the rest of the immune system. When activated, helper T cells secrete cytokines, which attract and activate B cells, cytotoxic T cells, NK cells, macrophages, and other cells of the immune system. Cytokines are the various proteins that mediate the immune response. These do not migrate to injury sites.
A client was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response? A. Effector B. Proliferation C. Response D. Recognition
B. Proliferation Explanation: In the proliferation stage, T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. This does not occur in the response, recognition, or effector stages.
A nurse is planning a client's care and is relating it to normal immune response. During which stage of the immune response do sensitized lymphocytes stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage
B. Proliferation stage Explanation: In the proliferation stage, 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. T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. This does not take place during the three preceding stages. During the recognition stage, which is the initial stage of the immune response, lymphocytes recognize antigens as foreign, or non-self. In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. This stage begins with the production of antibodies by the B lymphocytes in response to a specific antigen. The cellular response stimulates the resident lymphocytes to become cells that attack microbes directly rather than through the action of antibodies. These transformed lymphocytes are known as cytotoxic (killer) T cells. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader. The coupling initiates a series of events that in most instances results in total destruction of the invading microbes or the complete neutralization of the toxin.
A client was scratched by an old tool and developed a virulent staphylococcus infection. During the immune response, circulating lymphocytes containing the antigenic message returned to the nearest lymph node. During what stage of the immune response did this occur? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage
B. Proliferation stage Explanation: The recognition stage of antigens as foreign by the immune system is the initiating event in any immune response. The body must first recognize invaders as foreign before it can react to them. In the proliferation stage, the circulating lymphocyte containing the antigenic message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. In the response stage, the differentiated lymphocytes function either in a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader.
The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following? A. Thyroid gland B. Spleen C. Kidney D. Pancreas
B. Spleen Explanation: A history of surgical removal of the spleen, lymph nodes, or thymus may place the client at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system.
A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this? A. The movement of B cells in and out of lymph nodes B. The interactions that occur between T cells and B cells C. The differentiation between different types of T cells D. The universal role of the complement system
B. The interactions that occur between T cells and B cells Explanation: T cells interact closely with B cells, indicating that humoral and cellular immune responses are not separate, unrelated processes, but rather branches of the immune response that interact. Movement of B cells does not clearly show the presence of a unified immune system. The differentiation between types of T cells and the role of the complement system does not directly suggest a single immune system.
A client is informed of having a low white blood cell count and that the client is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse? A) "White blood cells are produced in the thymus gland." B) "White blood cells are produced in the lymphatic tissue." C) "White blood cells are produced in the bone marrow." D) "White blood cells are produced in the plasma."
C) "White blood cells are produced in the bone marrow." Explanation: White blood cells (leukocytes) are produced in the bone marrow. They are not produced in the plasma, thymus gland, or the lymphatic tissue.
A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected? A) Assess joint mobility using passive range of motion. B) Assess for hepatosplenomegaly by measuring abdominal girth C) Assess for ataxia using the finger-to-nose test and heel-to-shin test D) Review the urinalysis report for hematuria
C) Assess for ataxia using the finger-to-nose test and heel-to-shin test Explanation: Ataxia should be assessed when suspecting immune dysfunction in the neurosensory system. Joint movement, a urinalysis results positive for hematuria , and measuring abdominal girth are not used to assess for issues with the neurosensory system in relation to immune dysfunction.
Which assessment should be completed if immune dysfunction is suspected in the neurosensory system? A) Hematuria B) Burning upon urination C) Ataxia D) Urinary frequency
C) Ataxia Explanation: Ataxia should be assessed when immune dysfunction in the neurosensory system is suspected. Hematuria, discharge, and frequency of and burning upon urination are associated with the genitourinary system.
A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby: A) Antibodies are released into the bloodstream B) B-lymphocytes respond to a specific antigen C) Lymphocytes migrate to areas of the lymph node D) Antibodies reside in the plasma
C) Lymphocytes migrate to areas of the lymph node Explanation: Recognition of antigens as foreign, or non-self, by the immune system is the initiating event in any immune response. Recognition involves the use of lymph nodes and lymphocytes for surveillance. Lymph nodes are widely distributed internally throughout the body and in the circulating blood, as well as externally near the body's surfaces. They continuously discharge small lymphocytes into the bloodstream. These lymphocytes patrol the tissues and vessels that drain the areas served by that node.
The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function? A) Negative history for radiation therapy B) Surgical history of a partial gastrectomy C) Previous organ transplantation D) Surgical removal of the appendix
C) Previous organ transplantation Explanation: Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Removal of the appendix or stomach would have no effect on the immune system. A positive history for radiation therapy would affect the immune system, but not a negative history.
Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that: A) program T lymphocytes. B) increase the efficacy of antibiotics. C) filter bacteria from tissue fluid. D) eliminate cancer cells.
C) filter bacteria from tissue fluid. Explanation: The tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral and nasal passages, they can become infected and locally inflamed.
A client has a known allergy to peanuts, meaning that the client's immune system has identified peanuts as a foreign invader and has produced specific cells to attack if the client should come in contact with peanuts again. The formation of these specific cells is known as: A) cell-mediated response. B) inflammatory response. C) humoral response. D) memory response.
C) humoral response. Explanation: The B-cell lymphocytes mature in the bone marrow and migrate to the spleen and other lymphoid tissues such as the lymph nodes. When stimulated by T cells, the B cells become either plasma or memory cells. Plasma cells produce antibodies. Formation of antibodies is called a humoral response.
A nurse is reviewing a client's medication administration record in an effort to identify drugs that may contribute to the client's recent immunosuppression. What drug is most likely to have this effect? A. An antibiotic B. A nonsteroidal anti-inflammatory drug (NSAID) C. An antineoplastic D. An antiretroviral
C. An antineoplastic Explanation: Chemotherapy affects bone marrow function, destroying cells that contribute to an effective immune response and resulting in immunosuppression. Antibiotics in large doses cause bone marrow suppression, but antineoplastic drugs have the most pronounced immunosuppressive effect. NSAIDs and antiretrovirals do not normally have this effect.
A nurse is caring for a client who has had a severe antigen-antibody reaction. Which portion of the antigen is involved in binding with the antibody? A. Antibody agglutination B. Antigenic message C. Antigenic determinant D. Antibody response
C. Antigenic determinant Explanation: The specific area of an antigen that binds with an antibody-combining site and determines the specificity of the antigen-antibody reaction is referred to as the antigenic determinant. The T lymphocyte picks up the antigenic message, or "blueprint" of the antigen, which is the recognition of the antigen by the T lymphocyte. Agglutination is the clumping effect occurring when an antibody acts as a cross-link between two antigens. Antibody response is a type of immune response and is the immune system's second line of defense.
Diagnostic testing has revealed a deficiency in the function of a client's complement system. This client is likely to have an impaired ability to do what action? A. Protect the body against viral infection. B. Mark the parameters of the immune response. C. Bridge natural and acquired immunity. D. Collect immune complexes during inflammation.
C. Bridge natural and acquired immunity. Explanation: Complement has three major physiologic functions: defending the body against bacterial infection, bridging natural and acquired immunity, and disposing of immune complexes and the by-products associated with inflammation. Complement does not mark the parameters of the immune response; complement does not collect immune complexes during inflammation.
A client's recent diagnostic testing included a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the client's immunity? A. Humoral immune function B. Antigen recognition C. Cell-mediated immune function D. Antibody production
C. Cell-mediated immune function Explanation: A total lymphocyte count is a test used to determine cellular immune function. It is not normally used for testing humoral immune function and the associated antigen-antibody.
A client with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. Which immune response predominates in this situation? A. Humoral B. Nonspecific C. Cellular D. Antibody
C. Cellular Explanation: Most immune responses to antigens involve both humoral (antibody) and cellular responses, although only one predominates. During transplantation rejection, the cellular response predominates over the humoral (antibody) response. Transplantation rejection is not associated with nonspecific immune response. Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi.
A client with hepatitis B has been admitted to the medical intensive care unit with sepsis. Which immunity function was most likely compromised? A. Lymphatic system B. Passive immunity C. Complement system D. Monoclonal antibodies
C. Complement system Explanation: Circulating plasma proteins, known as complement, are made in the liver and activated when an antibody connects with an antigen. An impaired function of the liver caused by hepatitis B could result in the body being unable to fight a bacterial infection, which then results in sepsis. The complementary system is a natural immunity response. Passive/acquired immunity is gained from a source outside the body by contact of a previous disease or immunization. Monoclonal antibodies are lab grown and produce targeted antibodies for specific pathogenic organisms. The lymphatic system plays a role in normal vascular function. Changes and damage to this lymphatic system are associated with types of chronic liver damage, but these are not the most likely cause of sepsis. The only function that is made in the body and liver is the complement system, making this the best choice.
A client's current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by which cells? A. Suppressor T cells B. Memory T cells C. Cytotoxic T cells D. Complement T cells
C. Cytotoxic T cells Explanation: Cytotoxic T cells (also called CD8 + cells) participate in the destruction of foreign organisms, attacking the antigen directly by altering the cell membrane, causing cell lysis (disintegration), and releasing cytolytic enzymes and cytokines. Memory T cells are responsible for recognizing antigens from previous exposure and mounting an immune response; however, they do not participate in the direct destruction of foreign microorganisms. Suppressor T cells have the ability to decrease B-cell production, thereby keeping the immune response at a level that is compatible with health; however, they do not participate in the direct destruction of foreign microorganisms. The complement system does not exist as a type of T cell.
A client's natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances natural immunity? A. Cell cytoplasm B. Interstitial fluid C. Gastric secretions D. Cerebrospinal fluid
C. Gastric secretions Explanation: Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi. Not all body fluids are chemical barriers, however. Cell cytoplasm, interstitial fluid, and CSF are not normally categorized as chemical barriers to infection.
A gerontologic nurse is caring for a 78-year-old client who has a diagnosis of pneumonia. Which age-related change increases older adults' susceptibility to respiratory infections? A. Atrophy of the thymus B. Bronchial stenosis C. Impaired ciliary action D. Decreased diaphragmatic muscle tone
C. Impaired ciliary action Explanation: As a consequence of impaired ciliary action due to exposure to smoke and environmental toxins, older adults are vulnerable to lung infections. This vulnerability is not the result of thymus atrophy, stenosis of the bronchi, or loss of diaphragmatic muscle tone.
A client is responding to a microbial invasion and the client's differentiated lymphocytes have begun to function in either a humoral or a cellular capacity. During what stage of the immune response does this occur? A. The recognition stage B. The effector stage C. The response stage D. The proliferation stage
C. The response stage Explanation: In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader. In the recognition stage, the recognition of antigens as foreign, or nonself, by the immune system is the initiating event in any immune response. During the proliferation stage the circulating lymphocytes containing the antigenic message return to the nearest lymph node.
A nurse is planning the assessment of a client who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among which group? A. Young adults B. Native Americans/First Nations C. Women D. People of Hispanic descent
C. Women Explanation: Many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones. Sex hormones play definitive roles in lymphocyte maturation, activation, and synthesis of antibodies and cytokines. Autoimmune disorders in women, such as lupus and multiple sclerosis, may be linked to hormonal changes that can occur during puberty, pregnancy, and menopause. Young adults, Native Americans/First Nations and people of Hispanic descent are not known to have a higher incidence or prevalence of autoimmune disorders.
When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask? A) "When was your last menstrual period?" B) "Have you ever been treated for a sexually transmitted infection?" C) "Do you have abdominal pain or discomfort?" D) "Have you ever received a blood transfusion?"
D) "Have you ever received a blood transfusion?" Explanation: A history of blood transfusions is obtained, because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function.
A nurse is explaining treatment options to a client diagnosed with an immune dysfunction. Which statement by the client accurately reflects the teaching about current stem cell research? A) "Currently, stem cell transplantation has only been performed in the laboratory, but future research with embryonic stem cell transplants for humans with immune dysfunction has been promising." B) "Stem cell transplantation has been discontinued based on concerns about safety, efficacy, resource allocation, and human cloning." C) "Stem cell clinical trials have only been attempted in clients with acquired immune deficiencies, but plans are underway to begin human cloning using embryonic stem cells." D) "Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, and clinical trials using stem cells are underway in clients with a variety of disorders with an autoimmune component
D) "Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, and clinical trials using stem cells are underway in clients with a variety of disorders with an autoimmune component." Explanation: Research has shown that stem cells can restore an immune system that has been destroyed (Ko, 2012). Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, such as severe combined immunodeficiency; clinical trials using stem cells are underway in clients with a variety of disorders having an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis. Research with embryonic stem cells has enabled investigators to make substantial gains in developmental biology, gene therapy, therapeutic tissue engineering, and the treatment of a variety of diseases (Ko, 2012). However, along with these remarkable opportunities, many ethical challenges arise, which are largely based on concerns about safety, efficacy, resource allocation, and human cloning.
Which of the following cell types are involved in humoral immunity? A) Helper T lymphocyte B) Suppressor T lymphocyte C) Memory T lymphocyte D) B lymphocytes
D) B lymphocytes Explanation: B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.
A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand? A) Monocytes B) B cells C) Eosinophils D) Neutrophils
D) Neutrophils Explanation: 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.
What is the function of the thymus gland? A) Produce stem cells B) Programs B lymphocytes to become regulator or effector B cells. C) Develop the lymphatic system D) Programs T lymphocytes to become regulator or effector T cells.
D) Programs T lymphocytes to become regulator or effector T cells. Explanation: The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum. The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle. Options A, B, and C are incorrect.
A client is diagnosed with multiple site cancers and has received whole-body irradiation. The nurse is concerned about a compromised immune system in this client for which reason? A) Radiation causes an excess of circulating lymphocytes. B) Radiation causes a deficiency of circulating hemoglobin. C) Radiation causes an excess of circulating hemoglobin. D) Radiation destroys lymphocytes.
D) Radiation destroys lymphocytes. Explanation: Radiation destroys lymphocytes and decreases the ability to mount an effective immune response. Radiation is not associated with an excess of lymphocytes or an excess or deficiency of hemoglobin.
A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder? A) Excess cytokines cause tissue damage. B) Regulatory mechanisms fail to halt the immune response. C) The immune system recognizes one's own tissues as "foreign." D) The immune system recognizes one's own tissues as "self."
D) The immune system recognizes one's own tissues as "self." Explanation: The immune system's recognition of one's own tissues as "foreign" rather than self is the basis of many autoimmune disorders, including multiple sclerosis. When regulatory mechanisms fail to halt the immune response or excess cytokines are produced, pathology occurs (e.g., allergies, hypersensitivity).
A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to: A) acidosis because the spleen maintains acid-base balance. B) anemia because the spleen produces red blood cells. C) bleeding because the spleen synthesizes vitamin K. D) infection because the spleen removes bacteria from the blood.
D) infection because the spleen removes bacteria from the blood. Explanation: One function of the spleen is to remove bacteria from circulation; therefore, the client will be more susceptible to infection.
A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response? A. Specialized cells recognize and ingest cells that are recognized as foreign. B. T lymphocytes are assisted by cytokines to fight infection. C. Lymphocytes are stimulated to become cells that attack microbes directly. D. Antibodies are made by B lymphocytes in response to a specific antigen.
D. Antibodies are made by B lymphocytes in response to a specific antigen. Explanation: The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. Phagocytosis and direct attack on microbes occur in the context of the cellular immune response.
A client is being treated for cancer, and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which way? A. Causing apoptosis of cytokines B. Increasing interferon production C. Causing CD4+ cells to mutate D. Depressing antibody response
D. Depressing antibody response Explanation: Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. This specific nutritional deficit does not cause T-cell mutation, an increase in the production of interferons, or apoptosis of cytokines.
A client is fighting an active infection. What function will cytokines perform in this immune response? A. Determining whether a cell is foreign B. Determining if lymphokines will be activated C. Determining whether the T cells will remain in the nodes and retain a memory of the antigen D. Determining whether the immune response will be the production of antibodies or a cell-mediated response
D. Determining whether the immune response will be the production of antibodies or a cell-mediated response Explanation: Separate subpopulations of helper T cells produce different types of cytokines and determine whether the immune response will be the production of antibodies or a cell-mediated immune response. Cytokines do not determine whether cells are foreign, determine if lymphokines will be activated, or determine the role of memory T cells.
A nurse educator is developing a care plan concerning a risk of infection related to vascular insufficiency. Which disease and/or injury would most likely align with this nursing care plan? A. Transient ischemic attack (TIA) B. Major burns C. Chronic obstructive pulmonary disease (COPD) D. Diabetes
D. Diabetes Explanation: In diabetes. an increased incidence of infection has been associated with vascular insufficiency, neuropathy, and poor control of serum glucose levels. Recurrent respiratory tract infections are associated with COPD, so the risk of infection is more likely related to altered inspiratory and expiratory function and ineffective airway clearance. Major burns compromise the body's first line of defense, which is the skin. The risk of infection is related to skin integrity for burns. And clients with TIA are at risk for infection, typically from stroke-associated pneumonia.
A client being treated for bacterial pneumonia initially experienced dyspnea and a high fever but now claims to be feeling better and is afebrile. The client is most likely in which stage of the immune response? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage
D. Effector stage Explanation: The immune response culminates with the effector stage, during which offending microorganisms are killed by the various actions of the immune system. The client's improvement in health status is likely the result of this final stage in the immune response.
A nurse has admitted a client who has been diagnosed with urosepsis. Which immune response predominates in sepsis? A. Mitigated B. Nonspecific C. Cellular D. Humoral
D. Humoral Explanation: Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. For example, during transplantation rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant role. Neither mitigated nor nonspecific cell response is predominant in this situation.
A client's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at this client's site of inflammation? A. Eosinophils B. Red blood cells C. Lymphocytes D. Neutrophils
D. Neutrophils Explanation: Neutrophils are the first cells to arrive at the site where inflammation occurs. Eosinophils increase in number during allergic reactions and stress responses, but are not always present during inflammation. RBCs do not migrate during an immune response. Lymphocytes become active but do not migrate to the site of inflammation.
A neonate exhibited some preliminary signs of infection, but the infant's condition resolved spontaneously prior to discharge home from the hospital. This infant's recovery was most likely due to which type of immunity? A. Cytokine immunity B. Specific immunity C. Active acquired immunity D. Nonspecific immunity
D. Nonspecific immunity Explanation: Natural immunity, or nonspecific immunity, is present at birth. Active acquired or specific immunity develops after birth. Cytokines are proteins that mediate the immune response; they are not a type of immunity.
The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment? A. Percussion of the client's abdomen B. Palpation of the client's liver C. Auscultation of the client's apical heart rate D. Palpation of the client's lymph nodes
D. Palpation of the client's lymph nodes Explanation: During the assessment of immune function, the anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement. If palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Because of the central role of lymph nodes in the immune system, they are prioritized over the heart, liver, and abdomen, even though these would be assessed.
