Chapter 16 Inflammation and Immunity

What is the nurse's best response to a 38-year-old client with a large wound who does not want to receive a tetanus toxoid vaccination because he had a tetanus shot just 1 year ago? "Tetanus is a more serious disease and a "booster" is required every year to ensure adequate immunity and protection against it." "You may not need this vaccination now, I will check with your health care provider." "You need this vaccination because the strain of tetanus changes every year." "Because antibody production slows down as you age, it is better to take this vaccination as a booster to the one you had a year ago."

"You may not need this vaccination now, I will check with your health care provider."

What is the most important precaution for the nurse to teach a client who has few natural killer cells and the natural killer cells are not very active? -"You will need to avoid people with viral infections because it is harder now for you to develop antibodies." -"You will need to have yearly checkups because your risk for cancer development is greater now." -"You will be at an increased risk for developing allergies, so it will be necessary for you to avoid common allergens." -"You will no longer develop a fever when you have an infection, so you must learn to identify other symptoms of infection."

"You will need to have yearly checkups because your risk for cancer development is greater now."

Which number will the nurse calculate as the absolute neutrophil count (ANC) for a client whose differential includes: total WBCs 5300/mm3 (5.3 × 109/L ); segs 2800/mm3 (2.8 × 109/L); bands 200/mm3 (0.20 × 109/L); monos 250/mm3 (0.25 × 109/L); lymphs 2000/mm3 (2.0 × 109/L); eosins 25/mm3 (0.025 × 109/L); basos 25 (0.025 × 109/L)? 2800/mm3 (2.8 × 109/L) 3200/mm3 (3.2 × 109/L) 3000/mm3 (3.0 × 109/L) 2300/mm3 (2.3 × 109/L)

3000/mm3 (3.0 × 109/L)

Which client health problems will the nurse identify as an infectious process along with inflammation rather than inflammation alone? (Select all that apply.) Tendonitis Appendicitis Asthma Cystitis Anaphylaxis Sepsis

Appendicitis Cystitis Sepsis

Which type of immunity will the nurse initiate by administering an infusion of IV immunoglobulin to a client? Natural active immunity Artificial passive immunity Artificial active immunity Natural passive immunity

Artificial passive immunity

Which assessment finding on a client with no other health problems does the nurse consider the greatest potential threat to the client's immune system? Has old scar formation related to an appendectomy. Has poor oral hygiene and numerous dental caries. Displays orthostatic hypotension and is mildly dehydrated. Displays occasional skipped heartbeats during auscultation.

Has poor oral hygiene and numerous dental caries.

What type of health problem will the nurse expect to see in a client who has very few regulator T cells? Increased severity of allergic and other hypersensitivity reactions Decreased ability to recognize non-self cells Decreased immunoglobulin production Increased risk for cancer development

Increased severity of allergic and other hypersensitivity reactions

Which client laboratory response indicates to the nurse that granulocyte colony-stimulating factor therapy is successful? Increased lymphocytes Increased white blood cells Increased platelets Increased red blood cells

Increased white blood cells

Which differential count will the nurse report to the primary health care provider for a client whose white blood count indicates a total count of 10,000 cells/mm3 (10 × 109/L)? Eosinophils 200/mm3 (0.2 × 109/L) Lymphocytes 2100/mm3 (2.1 × 109/L) Segmented neutrophils 6000/mm3 (6 × 109/L) Monocytes 2000/mm3 (2 × 109/L)

Monocytes 2000/mm3 (2 × 109/L)

How do immune system cells differentiate between normal, healthy body cells and non-self cells within the body? -All normal, healthy body cells are considered a part of the immune system. -Immune system cells recognize normal healthy body cells by the presence of the nucleus, a structure that is lacking in non-self cells. -Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as "foreign" by immune system cells. -Non-self cells are easily identified by the immune system cells because non-self cells are much larger than normal, healthy body cells.

Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as "foreign" by immune system cells.

Which cell types provide protective responses during inflammation? Natural killer cell Basophils Eosinophils Platelets Macrophages Neutrophils

Platelets

With which client conditions will the nurse expect an inflammatory response without infection? (Select all that apply.) Poison ivy rash Otitis media Welt formation after a bee sting Blister formation from a burn Blister from a cold sore Acute myocardial infarction

Poison ivy rash Welt formation after a bee sting Blister formation from a burn Acute myocardial infarction

Which precautions are most important for the nurse to teach as part of health promotion for inflammation and immunity to an 88-year-old client? (Select all that apply.) Report any temperature elevation to your primary health care provider immediately. Get an influenza vaccination every year. Wear gloves when working in your garden. Avoid performing any level of aerobic exercise. Consider moving into an assisted living facility. Be sure to have a tuberculosis skin test every year.

Report any temperature elevation to your primary health care provider immediately. Get an influenza vaccination every year. Wear gloves when working in your garden.

What is the nurse's interpretation of a laboratory result that indicates a client has a high blood concentration of IgG directed against the human papilloma virus? The client is at risk for major hypersensitivity reactions to attenuated vaccines. The client is mounting an appropriate response to a recurrent exposure to the virus. The client is in the midst of his or her first response to human papilloma infection. The client is at increased risk for becoming ill from opportunistic infectious organisms.

The client is mounting an appropriate response to a recurrent exposure to the virus.

How will the nurse interpret a client's white blood cell count that has a total count of 9000 cells/mm3 (9 x 109/L) with a lymphocyte count of 4200 cells/mm3 (4.2 × 109/L)? The count indicates the client has an increased risk for infection. The client most likely has a viral infection. The count is completely normal. The client most likely has a bacterial infection.

The client most likely has a viral infection.

Which types of problems will the nurse expect to find more frequently in a client who does not make adequate amounts of immunoglobulin A (IgA)? (Select all that apply.) Upper respiratory infections Cystitis Excessive bleeding Contact dermatitis Anaphylaxis Diarrhea

Upper respiratory infections Cystitis Diarrhea