Ch 35 Assessment of the Immune System PrepU
A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client? A) Assure the client that this is a normal reaction B) Gently rub the swollen area to accelerate blood flow C) Advise the client to use prescribed analgesics D) Apply ice packs to reduce the swelling
A) Assure the client that this is a normal reaction Explanation: The nurse should assure the client that this is a normal reaction. When disease-specific antigens are injected, the injection area swells as a result of the client developing antibodies against the antigen that is introduced. The nurse should also keep in mind that the client is not necessarily actively infectious if the test result is positive. Rubbing the area gently or even applying ice packs may only aggravate the swelling. The swollen area should be left open to heal by itself. The nurse should await the physician's instructions before advising the client to use any prescribed analgesics.
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health? A) The client appears mildly ill, listless, and disheveled. B) The client has a blood pressure of 120/72 mm Hg. C) The client is alert and oriented to all spheres. D) The client has palpable peripheral pulses in the upper extremities.
A) The client appears mildly ill, listless, and disheveled. Explanation: The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then performs a more comprehensive examination.
A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which reason? A) Blood products cause lower antibody titers. B) Exposure to foreign antigens may cause altered immune function. C) Blood products cause a high risk for exposure to HIV. D) Blood products cause a high risk for hepatitis B.
B) Exposure to foreign antigens may cause altered immune function. Explanation: A history of blood transfusions is obtained because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function. There is only a small risk for HIV transmission from transfusions received after 1985. The risk for exposure to hepatitis B from blood transfusions is extremely small.
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte. A) Suppressor T cell B) Helper T cell C) Cytotoxic T cell D) Memory T cell
C) Cytotoxic T cell Explanation: The cytotoxic T cells (also known as killer T cells) attack the antigen directly and release cytotoxic enzymes and cytokines.
A 34-year-old client is diagnosed with chronic hepatitis C. Testing reveals that the client is a candidate for treatment. The nurse anticipates that which therapy could be used to treat the client's condition? A) Interleukin-5 B) Erythropoietin C) Interferon D) Monoclonal antibodies
C) Interferon Explanation: Interferons are used to treat immune-related disorders (e.g., multiple sclerosis) and chronic inflammatory conditions (e.g., chronic hepatitis).
Which of the following cell types are involved in humoral immunity? A) Suppressor T lymphocyte B) Memory T lymphocyte C) Helper T lymphocyte D) B lymphocyte
D) B lymphocyte Explanation: B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.
The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents? A) Neutrophils B) Eosinophils C) Basophils D) Macrophages
D) Macrophages Explanation: Macrophages move toward the antigen and destroy it. Eosinophils are only slightly phagocytic.
Which type of immunity becomes active as a result of infection by a specific microorganism? A) Artificially acquired active immunity B) Artificially acquired passive immunity C) Naturally acquired passive immunity D) Naturally acquired active immunity
D) Naturally acquired active immunity Explanation: Naturally acquired active immunity occurs as a result of an infection by a specific microorganism. 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.
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 who has developed kidney failure is discussing options with the health care provider for treatment. What does the nurse understand that kidney failure is associated with? A) A deficiency in phosphorus B) A deficiency in circulating lymphocytes C) Increased amount of macrophages D) Decreased amount of WBCs
B) A deficiency in circulating lymphocytes Explanation: Renal failure is associated with a deficiency in circulating lymphocytes.
The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication? A) colony-stimulating factor B) interferons C) interleukins D) tumor necrosis factor
B) interferons Explanation: Interferons are chemicals that primarily protect cells from viral invasion. They enable cells to resist viral infection and slow viral replication. They have been used as adjunctive therapy in the treatment of AIDS. Interferons also have been used to treat some forms of cancer such as leukemia because they stimulate NK cell activity. Interferon is administered parenterally because digestive enzymes destroy its protein structure.
Which stage of the immune response occurs when the differentiated lymphocytes function in either a humoral or a cellular capacity? A) Recognition stage B) Proliferation stage C) Effector stage D) Response stage
D) Response stage Explanation: In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. Recognition of antigens as foreign or non-self by the immune system is the initiating event in any immune response. In the proliferation stage, the circulating lymphocytes containing the antigenic message return to the nearest lymph node. In the effector stage, either the antibody of the humoral response of the cytotoxic T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader.
A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function? A) Previous organ transplantation B) Surgical history of a splenectomy C) History of radiation therapy D) Surgical removal of the appendix
D) Surgical removal of the appendix Explanation: Removal of the appendix would have no direct effect on the immune system. Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Radiation therapy destroys lymphocytes. The spleen is an important part of the immune system, and removal of it increases the client's risk for poor immune function.
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) The immune system recognizes one's own tissues as "self." B) Excess cytokines cause tissue damage. C) Regulatory mechanisms fail to halt the immune response. D) The immune system recognizes one's own tissues as "foreign."
D) The immune system recognizes one's own tissues as "foreign." 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).
The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following? A) Plasma, which depletes the body's store of calcitonin B) Plasma, which depletes the body's store of catecholamines C) Serum, which depletes the body's store of glucagon D) Serum, which depletes the body's store of immunoglobulins
D) Serum, which depletes the body's store of immunoglobulins Explanation: Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. Loss of serum or plasma does not deplete the body of catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas).
You are working on a transplant unit and you know to carefully monitor your clients. What is the rationale for closely monitoring clients taking immunosuppressive drugs? A) Because of an increased risk of respiratory or urinary system infection B) Because of an increased risk of skin and hair problems C) Because of an increased risk of blood-related complications D) Because of an increased risk of heart failure
A) Because of an increased risk of respiratory or urinary system infection Explanation: After organ transplantation, the client's immune system may attack the new organ's cells because it recognizes them as 'nonself.' Therefore, drugs are used to intentionally suppress the immune system. For example, azathioprine (Imuran), cyclosporine (Sandimmune), and muromonab-CD3 (Orthoclone OKT3) are immunosuppressive drugs. The nurse should follow agency guidelines for controlling infectious diseases or protecting the client who is immunosuppressed. The nurse should observe such clients for signs and symptoms of infection such as fever, sore throat, productive cough, and dysuria. Immunosuppressive drugs do not cause skin or hair problems or any blood-related complications. Heart failure, infusion reactions, and life-threatening infections are associated with taking infliximab.
A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis? A) Engulfment and digestion of bacteria and foreign material B) Conversion of memory cells to plasma cells C) Release of chemicals to destroy bacteria and foreign material D) Removal of bacteria and dead blood cells from circulation
A) Engulfment and digestion of bacteria and foreign material Explanation: Phagocytosis is the process of engulfing and digesting bacteria and foreign materials. It does not involve the release of chemicals or conversion of memory cells to plasma cells. The macrophages in the spleen remove bacteria and dead blood cells from circulation.
You are caring for a client on tube feedings. The physician has ordered Osmolite HN as the feeding formula for the client. The family asks why the physician has ordered Osmolite HN instead of another formula to feed their family member. What is an important reason that tube-feeding formulas, such as Impact, Osmolite HN, or Peractive, be recommended to clients? A) To enhance the production of lymphocytes and NK cells B) To block tumor necrosis factor C) To stimulate the immune system to attack tumor cells D) To suppress immune system function
A) To enhance the production of lymphocytes and NK cells Explanation: Immune-enhancing tube-feeding formulas enhance the production of lymphocytes and NK cells, resulting in increased cell-mediated immunity. Drugs such as azathioprine, cyclosporine, and muromonab-CD3 suppress immune system function, while infliximab and etanercept minimize inflammation by blocking tumor necrosis factor. Aldesleukin is used as biologic therapy for clients who do not respond to conventional cancer treatment. Aldesleukin stimulates the immune system's ability to attack tumor cells.
The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the: A) Upper left quadrant of the abdomen. B) Upper mediastinum. C) Lower right abdomen. D) Lower margin around the liver.
A) Upper left quadrant of the abdomen. Explanation: The spleen is located to the left of the stomach, in the upper left of the abdomen. It plays an important role in the immune system.
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include: A) neutrophils and monocytes. B) lymphokines and suppressor T cells. C) regulator T cells and helper T cells. D) plasma cells and memory cells
A) neutrophils and monocytes. Explanation: Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.
During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess? A) Phagocytic immunity B) Acquired immunity C) Humoral immunity D) Natural immunity
B) Acquired immunity Explanation: Acquired immunity usually develops as a result of prior exposure to an antigen 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 white blood cells (WBCs), which 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 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) Neutrophils C) Eosinophils D) B cells
B) 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.
A 15-year-old client has been brought to the clinic by their mother and is suspected of having an immune system disorder. What tests would you expect to be ordered for this young client? A) Plasmapheresis B) Sedimentary rate C) Complete blood count with differential D) Complete chemistry panel
C) Complete blood count with differential Explanation: Laboratory tests are used to identify immune system disorders. They usually include a complete blood count with differential. Protein electrophoresis screens for diseases associated with a deficiency or excess of immunoglobulins. T-cell and B-cell assays (or counts) and the enzyme-linked immunosorbent assay may be performed. Options A, B, and D are not diagnostic of immune disorders.
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications? A) Give the client one medicine at a time and observe for allergic reactions. B) Administer the medications that the physician ordered. C) Call the pharmacy and let them know the client has several drug allergies. D) Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.
D) Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. Explanation: Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy but still maintains responsibility for the medications administered.
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) "Stem cell transplantation has been discontinued based on concerns about safety, efficacy, resource allocation, and human cloning." B) "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." C) "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." 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.
The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response? A) Diuretics B) Corticosteroids C) Angiotensin-converting enzyme inhibitors (ACE-I) D) Nonsteroidal anti-inflammatory
B) Corticosteroids Explanation: The nurse obtains a history of immunizations, recent and past infectious diseases, and recent exposure to infectious diseases. The nurse reviews the client's drug history because certain drugs, such as corticosteroids, suppress the inflammatory and immune responses. Nonsteroidal anti-inflammatory medication does not suppress the inflammatory and immune responses of Crohn's disease. An ACE-I prevents the conversion of angiotensin I to angiotensin II and does not suppress the inflammatory or immune response. Diuretics also do not suppress the immune response but help reduce excess fluid from the kidneys.
The nurse is caring for a client with a suspected diagnosis of HIV. The nurse is preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV? A) Advise the client to take off any ornaments and metallic objects. B) Advise the client to avoid excess fluid intake. C) Obtain a written consent from the client. D) Advise the client to abstain from having intercourse.
C) Obtain a written consent from the client. Explanation: It is important that the nurse obtain written consent from the client before performing an HIV test and keep the results of HIV test confidential. The nurse may not ask the client to avoid excess fluid intake or abstain from intercourse before the tests. The client also need not take off ornaments and metallic objects worn unless they are likely to interfere with the test results.
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 destroys lymphocytes. D) Radiation causes an excess of circulating hemoglobin.
C) 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.
