Chapter 31: Assessment of Immune Function
When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask? "Have you ever been treated for a sexually transmitted infection?" "When was your last menstrual period?" "Do you have abdominal pain or discomfort?" "Have you ever received a blood transfusion?"
"Have you ever received a blood transfusion?"
A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response? "It means you are very sensitive to something inside of yourself." "It is a hyperimmune response to something in the environment that is usually harmless." "It is a muted response to something in the environment." "It is a harmless reaction to something in the environment."
"It is a hyperimmune response to something in the environment that is usually harmless."
A client with an autoimmune disorder asks, "Why is autoimmune disease more prevalent in the women in my family?" Which response will the nurse make to this client? "There is not enough evidence to prove this." "It's because you take better care of your family than yourself." "Women have more stress than men and it weakens immunity." "It's believed to be caused by the differences in the sex hormones."
"It's believed to be caused by the differences in the sex hormones."
The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine? A 24-year-old client who is pregnant A 17-year-old client who will be attending college and living in a dormitory A 32-year-old client who has never had chickenpox A 65-year-old client who had chicken pox when he was 12 years old
A 65-year-old client who had chicken pox when he was 12 years old
A client has breast cancer. The nurse is concerned about a compromised immune system in this client for which reason? Antineoplastic drug therapy Excess circulating lymphocytes Deficient circulating antibodies Excess circulating hemoglobin
Antineoplastic drug therapy
Which assessment should be completed if immune dysfunction is suspected in the neurosensory system? Ataxia Hematuria Urinary frequency Burning upon urination
Ataxia
The client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client? Avoid red meat for 48 to 72 hours before the test. Avoid strenuous physical activity for 24 hours before the test. Avoid antihistamines and cold preparations for 48 to 72 hours before the test. Avoid sunlight for 48 to 72 hours before the test.
Avoid antihistamines and cold preparations for 48 to 72 hours before the test.
A nurse is caring for a client undergoing evaluation for possible immune system disorders. Which intervention will best help support the client throughout the diagnostic process? Accompany the client to the diagnostic tests Educate the client about the diagnostic procedures and answer their questions about the possible diagnosis Encourage the client to ask the physician for information about treatment options for the possible diagnosis Assist the client with scheduling the procedures
Educate the client about the diagnostic procedures and answer their questions about the possible diagnosis
A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells? Etanercept (Enbrel) infliximab (Remicade) Epoetin alfa (Epogen) Adalimumab (Humira)
Epoetin alfa (Epogen)
A 6-year-old client is diagnosed with a viral infection of the respiratory system. Which will most likely be trying to fight the antigen? Interferons Complements Self-antigens B cells
Interferons
The nurse is performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph nodes on the left. What should the nurse document? (Select all that apply.) Location Size Consistency Reports of tenderness Temperature
Location Size Consistency Reports of tenderness
Which type of immunity becomes active as a result of infection by a specific microorganism? Naturally acquired active immunity Artificially acquired active immunity Naturally acquired passive immunity Artificially acquired passive immunity
Naturally acquired active 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? Eosinophils Neutrophils B cells Monocytes
Neutrophils
What is the function of the thymus gland? Produce stem cells Programs B lymphocytes to become regulator or effector B cells. Develop the lymphatic system Programs T lymphocytes to become regulator or effector T cells.
Programs T lymphocytes to become regulator or effector T cells.
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? Radiation destroys lymphocytes. Radiation causes an excess of circulating lymphocytes. Radiation causes a deficiency of circulating hemoglobin. Radiation causes an excess of circulating hemoglobin.
Radiation destroys lymphocytes.
Which condition is associated with impaired immunity relating to the aging client? Antibody production increases Renal function decreases Skin becomes thicker Incidence of autoimmune disease decreases
Renal function decreases
T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do? T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person. T-cell and B-cell lymphocytes respond to the body's invasion by macrophages. T-cell and B-cell lymphocytes react to the body's lack of B12 . T-cell and B-cell lymphocytes distinguish harmful treatments from curative treatments.
T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.
Which statement accurately reflects current stem cell research? Stem cell transplantation cannot restore immune system functioning. Stem cell transplantation has been performed in the laboratory only. Clinical trials are underway only in clients with acquired immune deficiencies. The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.
The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.
Which statement accurately reflects current stem cell research? Stem cell transplantation cannot restore immune system functioning. Stem cell transplantation has been performed in the laboratory only. Clinical trials are underway only in clients with acquired immune deficiencies. The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.
The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.
A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection? Through the mucous membranes of the throat Through the skin Breathing in airborne dust From being outside in the cold weather and decreasing resistance
Through the mucous membranes of the throat
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? "Stem cell transplantation has been discontinued based on concerns about safety, efficacy, resource allocation, and human cloning." "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." "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." "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."
"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."
The nurse is obtaining the medical history of a client with Crohn's disease. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response? Nonsteroidal anti-inflammatory Angiotensin-converting enzyme inhibitors (ACE-I) Diuretics Corticosteroids
Corticosteroids
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte. Helper T cell Suppressor T cell Cytotoxic T cell Memory T cell
Cytotoxic T cell
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? Macrophages Helper T cells B cells Cytotoxic T cells
Cytotoxic T cells
The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function? Previous organ transplantation Surgical removal of the appendix Negative history for radiation therapy Surgical history of a partial gastrectomy
Previous organ transplantation
The nurse is beginning the physical examination of a client with fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health? The client appears mildly ill, listless, and disheveled. The client has a blood pressure of 120/72 mm Hg. The client is alert and oriented to all spheres. The client has palpable peripheral pulses in the upper extremities.
The client appears mildly ill, listless, and disheveled.
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have? Naturally acquired active immunity Artificially acquired active immunity Passive immunity transferred by the mother There is no immunity passed down from mother to child.
Passive immunity transferred by the mother
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: Upper mediastinum. Lower right abdomen. Upper left quadrant of the abdomen. Lower margin around the liver.
Upper left quadrant of the abdomen.
Which of the following protective responses begin with the B lymphocytes? Humoral Phagocytic Cellular Recognition
Humoral
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? IgG IgA IgM IgE
IgE
The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses? Polypharmacy Immunosenescence Reduced vitamin intake Decline in self-care activities
Immunosenescence
An elderly client is diagnosed with a respiratory infection. While reviewing age-related changes in the immune system, what would the nurse identify as having contributed to this client's infection? Impaired ciliary action from exposure to environmental toxins Failure of the immune system to differentiate "self" from "non-self" Decreased phagocytosis by Kupffer cells Decreased sensation and slowing of reflexes
Impaired ciliary action from exposure to environmental toxins
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? Eosinophils Macrophages Basophils Neutrophils
Macrophages
Which type of cell is capable of directly killing invading organisms and producing cytokines? Null lymphocytes Natural killer cells Memory cells Cytotoxic T cells
Natural killer cells
A child is brought to the clinic with a rash and is subsequently diagnosed with measles. The parent reports also having had measles as a young child. What type of immunity to measles develops after the initial infection? Naturally acquired active immunity Artificially acquired active immunity Naturally acquired passive immunity Artificially acquired passive immunity
Naturally acquired active immunity
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? "White blood cells are produced in the plasma." "White blood cells are produced in the thymus gland." "White blood cells are produced in the lymphatic tissue." "White blood cells are produced in the bone marrow."
"White blood cells are produced in the bone marrow."
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? Toxins of invading antigens are neutralized. The invading antigens link together (agglutination). The invading antigens precipitate. T-cell lymphocytes survey proteins in the body and attack the invading antigens.
T-cell lymphocytes survey proteins in the body and attack the invading antigens.
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: filter bacteria from tissue fluid. increase the efficacy of antibiotics. eliminate cancer cells. program T lymphocytes.
filter bacteria from tissue fluid.
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: infection because the spleen removes bacteria from the blood. bleeding because the spleen synthesizes vitamin K. acidosis because the spleen maintains acid-base balance. anemia because the spleen produces red blood cells.
infection because the spleen removes bacteria from the blood.
