exam 5 immune questions ch 17, 20
A client has a white blood cell change in which the number of suppressor T-cells is way below normal and asks the nurse which type of health problem(s) could be expected as a result of this deficiency. What is the nurse's best response? A. "You will need to receive booster vaccinations more often because your ability to make antibodies is reduced." B. "Try to avoid crowds and people who are ill because you are now more susceptible to bacterial and viral infections." C. "You will be more prone to allergic reactions when exposed to allergens or drugs." D. "Your risk for cancer development is increased."
A
What are the clinical manifestations of systemic lupus erythematosus that are caused by an immune complex reaction? a. vasculitis, glomerulonephritis, nephritis b. HTN, hyperlipidemia c. excessive mucus and secretions d. angioedema, urticaria, stridor
a
a patient is admitted with pneumonia and has developed sepsis. what can the findings from a diff WBC count reveal about this patient? a. whether an infection is bacterial or viral b. whether the patient has active immunity c. the tissue type from the human leukocyte d. the type of antibody response occurring
a
in caring for a patient with severe hypersensitivity response, under what circumstances would the nurse prepare to assist the HCP with a tracheostomy? a. patient has excessive laryngeal edema and intubation is impossible b. patient anaphylaxis has a previous history of angioedema c. patient has wheezing, dyspnea, hypoxia, and cyanosis d. patient is unable to give a clear history but has respiratory distress
a
the nurse is assessing a patient experiencing a cytotoxic reaction to IV drugs. what is the nurse's first action? a. d/c drug administration b. dec. the infusion rate c. change the IV tubing d. call the RRT
a
the patient's leg wound has increased blood flow (hyperemia) and swelling., the nurse recognizes this as stage 1 in the sequence of inflammation process. what would be considered normal outcome for this stage? a. symptoms usually subside within 24-72 hours b. symptoms will resolve after antibiotic therapy c. symptoms are not normal and should be reported d. symptoms will disappear if the leg is elevated
a
what precaution or intervention has the highest priority for a patient going home on maintenance drugs after receiving a kidney transplant? a. monitoring for bacterial and fungal infections b. avoiding the use of table salt c. measuring abd girth daily d. avoiding blood donation
a
which allergy management strategy is the best for a patient who has a history of allergic asthma? a. practicing avoidance b. undergoing desnsitization c. taking corticosteroids d. carrying an automatic epinephrine injector
a
which clinical condition best represents a type IV stimulated hypersensitivity? a. poison ivy b. graves' disease c. myasthenia gravis d. vasculitis
a
A client recently admitted to the hospital with a UTI is to receive the first dose of an antibiotic intravenously. Before checking the five rights prior to administration, what is the nurse's first action? a. Review the clinical records and ask the client about any known allergies. b. Check with the pharmacy for any known allergies for this client. c. Check the client's identification band for any allergies. d. Ask the nurse who previously cared for the client about any known allergies.
a The nurse's first action is to check the client's clinical record for any known hypersensitivities as well as asking the client about any known allergies.The pharmacy is not responsible for obtaining information on all of the client's known allergies. Checking the client's identification band for allergies is part of the "five rights" process at the bedside before the medication is given. Asking the previous nurse is not an appropriate safety measure before medication administration.
which patients have factors that may affect the function of the immune system? select all that apply. a. patient has been on a severely limited diet for several weeks to quickly lose weight b. patient is homeless and is continuously seeking shelter for cold weather conditions c. patient is on multiple medications, including corticosteroids and a NSAIDs d. Patient is a 30 yo adult with a family history of HTN and high cholesterol e. patient is 84 yo and lives alone in her own house f. patient has type 2 DM that is well controlled with oral antidiabetic medication
a, b, c, e, f
An older resident living in a long-term care facility asks for help to go to the bathroom more frequently than usual. the nurse suspects a urinary tract infection. what changes in the immune system of an older adult should the nurse keep in mind? select all that apply. a. older adults are more at risk for bacterial and fungal infections in the genitourinary tract b. older adults may have an infection but now show expected changes in WBC counts c. older adults may not have a fever during inflammatory or infectious episodes d. urinalysis results for older patients are more likely to show false negative results e. older patients are less likely to become septic because of history of antibody-antigen activity f. neutrophil counts may be normal, but activity is reduced, increasing the risk for infection
a, b, c, f
the nurse is preparing a teaching plan for the patient and family on how to use and care for an automatic epinephrine injector. which essential points must the nurse include? select all that apply. a. "keep the device with you at all times." b. "you can inject the drug right through your pants." c. "when you use the device, call your doctor and rest in bed for 24 hours." d. "protect the device from light and avoid temperature extremes." e. "keep the safety cap in place until you are ready to use the device." f. "inject yourself when you get short of breath."
a, b, d, e
A client is prescribed prednisone for treatment of a type I hypersensitivity reaction. The nurse plans to monitor the client for which adverse effects? select all that apply. a. Fluid retention b. Gastric distress c. Hypotension d. Infection e. Osteoporosis
a, b, d, e Prednisone is a corticosteroid that may cause fluid and sodium retention. It can cause gastric distress and irritation and usually is taken with food or an antacid. Prednisone decreases the immune response, increasing the susceptibility for infection. It can also cause osteoporosis.Hypertension (not hypotension) is an adverse effect of prednisone.
in which conditions is the inflammatory response present? select all that apply. a. sprain injuries to joints b. appendicitis c. hypothyroidism d. myocardial infarction e. contact dermatitis f. allergic rhinitis
a, b, d, e, f
in which conditions might the nurse observe inflammation without infection? select all that apply. a. joint sprains b. MI c. otitis media d. blister formation e. allergic rhinitis f. contact dermatitis
a, b, d, e, f
for a patient who is having an anaphylactic reaction, which common symptoms will manifest almost immediately after being exposed to an allergen? select all that apply. a. erythema of the eyes and lips b. apprehension c. chills d. fever e. urticaria f. confusion
a, b, e
The nurse is assessing a client with suspected serum sickness. Which symptoms are consistent with serum sickness? select all that apply a. Arthralgia b. Blurred vision c. Lymphadenopathy d. Malaise e. Ptosis
a, c, d Serum sickness is a group of symptoms that occur after receiving serum or certain drugs. Symptoms include arthralgia (achy joints), lymphadenopathy (enlarged lymph nodes), fever, rash, malaise, and possibly polyarthritis and nephritis.Blurred vision and ptosis are not symptoms of serum sickness.
Which questions are most important for the nurse to first ask a client who comes to the emergency department with signs of severe angioedema? Select all that apply. A. "Are you able to swallow?" B. "When did you last eat or drink?" C. "Do you have an allergy to cortisone?" D. "What drugs do you take on a daily basis?" E. "Is there any possibility that you may be pregnant?" F. "Do any members of your family also have allergies?"
a, d
Which patient would benefit most from receiving a detailed explanation about human leukocyte antigens (HLAs)? a. patient has anorexia nervosa and is refusing to eat b. patient has an identical twin who needs a kidney transplant c. patient has strong family history of breast cancer d. patient is refusing to take antibiotics because of the side effects
b
Which type 1 hypersensitivity reaction requires immediate intervention by the nurse? a. rhinosinusitis b. bronchoconstriction c. urticaria d. pruritus
b
for a patient with anaphylaxis, which priority treatment does the nurse expect to administer? a. oral diphenhydramine b. IV epinephrine c. albuterol via high flow nebulizer d. IV corticosteroids
b
the nurse is reviewing the patient's medication orders and knows that the patient has an allergy to penicillin. which prescribed medications is the nurse most likely to question? a. analgesic for pain prn b. cephalosporin on call to surgery c. decongestant prn for rhinorrhea d. ACEI daily
b
A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? a. Intact skin and mucous membranes b. Self-tolerance c. Inflammatory response against invading foreign proteins d. Antibody-antigen interaction
b Self-tolerance is the process of recognizing and distinguishing between the body's own healthy self cells and non-self proteins and cells. The presence of different proteins on cell membranes makes the process of self-tolerance possible.The body has some defenses to prevent organisms from gaining access to the internal environment, such as intact skin and mucous membranes; however, they are not perfect—invasion of the body's internal environment by organisms often occurs. Inflammation provides immediate protection against the effects of tissue injury and invading foreign proteins. The inflammatory response is immediate but short-term against injury or invading organisms; it does not provide true immunity. Seven steps, known as phagocytosis (See Figure 17-6), are needed to produce a specific antibody directed against a specific antigen. These steps are necessary whenever the person is exposed to that antigen.
Which white blood cell types are involved in the development of antibody-mediated immunity? Select all that apply. A. Basophils B. B-lymphocytes C. Cytotoxic/cytolytic T-cells D. Helper/inducer T-cells E. Macrophages F. Natural killer cells G. Neutrophils
b, d, e
which disorders have an autoimmune basis? select all that apply. a. type 2 DM b. systemic lupus erythematosus c. hypothyroidism d. ulcerative colitis e. rheumatoid arthritis f. irritable bowel disease
b, d, e, f
Based on the nurse's knowledge of the concept of immunity, what is an example of self-tolerance? a. patient is given chemotherapy to eradicate the cancer cells b. antibiotic medication cures the patient's urinary tract infection c. skin front he patient's thigh is successfully grafted to a burn wound d. patient receives an uneventful blood transfusion during surgery
c
an older patient reports that he has been treated for tuberculosis in the distant past. he currently has a negative tuberculosis skin test. how does the nurse interpret the test results? a. patient does not currently have tuberculosis b. patient has incorrectly remembered being treated for tuberculosis c. in older patients, false negative tuberculosis results are a possibility d. test results are documented, and patient is to be retested annually
c
during assessment of a newly admitted patient, the nurse notes that the patient has a runny nose with clear drainage; pink, swollen mucosa; itchy, watery eyes; and a nasal-sounding voice. what does the nurse expect is the patient's diagnosis? a. hypersensitivity b. allergic response c. allergic rhinitis d. autoimmune response
c
during surgery, a patient undergoing a heart transplant experiences rejection of the organ. what type of rejection is this? a. acute b. chronic c. hyperacute d. transplant
c
how does the immune system respond to a graft when a transplant rejection occurs? a. collateral circulation develops and the transplanted organ becomes engorged b. opportunistic infections develop because the body is immunosuppressed c. host's immune system starts inflammation and immunologic actions to destroy nonself cells d. systemic tissue destruction occurs because of inability to differentiate self from nonself cells
c
the patient is receiving erythropoietin. if the therapy is successful in correctly stimulating stem cells, which laboratory results would the nurse expect to see? a. inc. in T-lymphocytes b. inc. in leukocytes c. inc. in erythrocytes d. inc. in platelets
c
the patient was treated in the ED for angioedema and now reports "feeling fine" and wants to go home. what is the nurse's best response? a. "sir, the doctor has not discharged you yet, so you have to stay, but we'll take good care of you." b. "let me check your v/s one more time, then i'll get the doctor to write a discharge order." c. "your symptoms are gone, but they could reoccur, so we have to observe you for a few more hours." d. "oh, you are not fishined yet. there is a lot of patient educaiton that we need to review."
c
which circumstance poses the greatest risk to good health via exposure to living organisms? a. a healthy adult nurse takes care of a patient with a bacterial infection of the leg b. a sanitation worker forgets to wear gloves when picking up a garbage can c. infant children in a daycare play together and share toys and food d. an animal care technician gives vaccinations and draws blood form cats and dogs
c
which description best characterizes autoimmunity? a. cell-mediated immune response that does not cause an antibody-mediated response b. the synthetic substances used to stimulate or suppress the response of the immune system c. Inappropriate immune response to one's own healthy cells and tissue d. an altered immune response that results in an immediate hypersensitivity reaction
c
which management strategy does the nurse expect when caring for a patient with an autoimmune disease? a. antibiotic drugs b. antihistamine drugs c. anti-inflammatory drugs d. bronchodilator drugs
c
which type of white blood cell does the body produce most? a. macrophages b. eosinophils c. neutrophils d. band neutrophils
c
why do older adults have an increased risk for autoimmune diseases? a. the number of neutrophils and macrophages are increased, as are their functions b. memory cells are damaged by age and they fail to react to antigens c. there is loss of recognition of self and an increase in circulating autoantibodies d. the WBC count is markedly decreased or absent
c
The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching? a. "I will be on this medicine for the rest of my life." b. "I must undergo regular kidney function tests." c. "I must regularly monitor my blood sugar." d. "My gums may become swollen because of this drug."
c Further teaching is needed when the client says, "I must regularly monitor my blood sugar." Blood sugar is not affected by taking cyclosporine, so the client has no need to monitor blood sugar.The client must take cyclosporine for the rest of his or her life. (See chart 17-2) Kidney dysfunction is a side effect of cyclosporine, so regular monitoring is required. Swollen gums are a side effect of taking cyclosporine.
Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? a. Report the need for desensitization therapy. b. Convey the need for pharmacologic therapy to the health care provider. c. Communicate the need for avoidance therapy to the health care team. d. Discuss symptomatic therapy with the health care provider.
c The best nursing action is to communicate the need for avoidance therapy to the health care team. Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins.Desensitization therapy is administered via allergy shots when allergens have been identified and cannot easily be avoided. Discussing the need for pharmacologic therapy might be indicated if signs of type I or type IV hypersensitivity exist, but this is not a preventive measure. Symptomatic therapy interventions such as an epinephrine pen, antihistamines, and corticosteroids are not preventive but are effective only after the hypersensitivity reaction has already occurred.
The action of which cell types must be suppressed to prevent acute rejection of transplanted organs? Select all that apply. a. eosinophils b. suppressor T-cells c. natural killer cells d. cytotoxic/cytolytic T-cells e. helper/inducer T-cells f. neutrophils
c, d
Which person is most likely to be immunocompetent? a. 79 yo male who lives independently, exercises daily, and eats balanced meals b. 25 yo female who drinks alcohol and who stays out late every night with her friends c. 6 yo male who is energetic but frequently has minor upper respiratory infections d. 45 yo female who works daily in her garden and eats a vegetarian diet
d
Which type of infection is most likely to result in a left shift (bandemia) that indicates an increased number of immature neutrophils? a. viral infection b. parasitic infection c. fungal infection d. bacterial infection
d
a nurse is exposed to a viral infection at work. after several days, the nurse fully recovers and returns to work. what is the role of the memory cell in relation to the nurse's viral illness? a. the memory cell reminds the nurse's healthy cells to function after recovery b. if the nurse develops other viral infections, the memory cell seeks out an antigen match c. the memory cell prevents viral shedding from the nurse to patients who are immunocompromised d. when the nurse is reexposed to the same antigen, the memory cell will produce antibodies
d
a patient in anaphylaxis is at risk for respiratory failure. which assessment finding prompts the nurse to prepare equipment to assist the HCP to intubate the patient? a. crackles b. hypoxemia c. wheezing d. stridor
d
production of immune cells will be most jeopardized by which event? a. patient's thymus gland atrophies because of the aging process b. patient's spleen is removed because of a serious car accident c. patient has liver failure secondary to alcohol abuse d. patient develops a bone marrow disorder
d
the nurse is caring for a patient and suspects anaphylaxis. what priority action does the nurse perform? a. place the patient on a cardiac monitor and observe for arrhytmias b. insert a large-bore IV line with NS c. ask the patient to describe previous response to various types of allergens d. apply oxygen using a high flow, nonrebreather mask at 90-100%
d
which outcome statement reflects one of the goals of drug therapy for autoimmune disease? a. the patient lists steps to take in care of a hypersensitivity response b. the patient demonstrates a respiratory rate within the normal range c. the patient verbalizes feelings of reduced anxiety and apprehension d. the patient retains enough immunity to prevent serious infections
d
The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. Zafirlukast works by which mechanism? a. Blocking histamine from binding to receptorsZ b. Preventing synthesis of mediators c. Preventing mast cell membranes from opening d. Blocking the leukotriene receptor
d Zafirlukast is a leukotriene antagonist that works by preventing the occurrence of allergic rhinitis by blocking the leukotriene receptor.Zafirlukast is not an antihistamine. Antihistamines such as diphenhydramine (Benadryl) block histamines from binding to receptors. Zafirlukast is not a corticosteroid. Corticosteroids prevent synthesis of mediators. Mast cell-stabilizing drugs such as cromolyn sodium (Nasalcrom) prevent mast cell membranes from opening when an allergen binds to immunoglobulin E; zafirlukast is not a mast cell-stabilizing drug.
to combat rejection of a transplanted kidney, the patient is prescribed IV dalizumab. which question is the nurse most likely to ask to assess for side effects of this medication? a. "are you having any nausea, vomiting, or abdominal discomfort?" b. "have you noticed bruising or bleeding when brushing your teeth?" c. "do you notice unusual fatigue or feelings of lightheadness?" d. "have you experienced any tremors or muscular weakness?"
a
under what circumstance are the tissue mast cells most likely to be involved in the immune response? a. person has an allergic reaction to peanuts b. person cuts hand while chopping vegetables c. person is sitting by someone who is coughing d. person has a flare up of rheumatoid arthritis
a
which nursing intervention is the most important for the nurse to perform before administering any drug or therapeutic agent to an adult patient? a. ask the patient about allergies to drugs or other substances b. check the medication administration record for allergic response to drugs c. make sure that emergency medications are readily available d. be aware of types of drugs that are likely to cause allergic reactions
a
a patient who had a kidney transplant 5 years ago is experiencing progressively reduced function of the organ. which intervention is appropriate for this patient? a. patient should be admitted to intensive care for observation and possible dialysis b. patient should be educated about retransplantation; related living donor should be sought c. drug management may limit the damage and allow the graft to be maintained d. patient should be immediately prepped surgical removal of the organ
b
for which patient circumstance would it be safe to prescribe a disease-modifying antirheumatic drug, such as adalimumab? a. patient has been in remission of cancer for 5 years b. patient is breastfeeding a newborn infant c. patient was treated for TB 15 yrs ago d. patient is currently being treated for early HF
b
in what way is antibody-mediated immunity different from cell-mediated immunity? a. AMI is more powerful than CMI b. AMI can be transferred from one person to another; CMI cannot c. CMI requires constant re-exposure for "boosting"; AMI does not d. CMI requires inflammatory actions; AMI is independent of inflammatory actions
b
the HCP writes a Rx for the patient to be immunized with the flu vaccine. which type of immunity does the nurse provide the patient by injecting this vaccine? a. natural active immunity b. artificial active immunity c. adaptive immunity d. passive immunity
b
the nurse has just given an african-american patient a first-time dose of an ACEI. which assessment is most important for this patient? a. observes for any untoward effects of any medication b. watches for angioedema and laryngeal edema c. checks pulse and BP before and after medication d. monitors for excessive drowsiness and confusion
b
the nurse is performing a physical assessment on an adult with no known health problems. Which assessment finding poses the greatest potential threat to the patient's immune system? a. has old car formation related to an appendectomy b. has poor oral hygiene and numerous dental caries c. displays occasional skipped heartbeats during auscultation d. displays orthostatic hypotension and is mildly dehydrated
b
the nurse is reviewing the patient's medication administration record and sees that the patient takes muromonab-CD3. what question is the nurse most likely to ask? a. "when were you first diagnosed with cancer?" b. "when was your organ transplant performed?" c. "is the medication controlling your allergy symptoms?" d. "are you still having symptoms of Infection?"
b
what is the clinical significance of the absolute neutrophil count (ANC)? a. high numbers of mature neutrophils are seen only in patients with severe sepsis b. the higher the number of mature circulating neutrophils, the greater the resistance to infection c. low ANC suggests that the infection is resolving because total number is depleted d. low ANC occurs when antibiotic therapy successfully takes over for the neutrophils
b
which cell types associated with the inflammatory response participate in phagocytosis? a. neutrophils and eosinophils b. macrophages and neutrophils c. macrophages and eosinophils d. eosinophils and basophils
b
which patient is most likely to the best candidate for desensitization therapy for allergies? a. patient lives on a farm in a remote area and suffers from hay fever b. patient lives in an urban area and has allergies to animal dander c. patient travels frequently outside the US and has seasonal allergies d. patient lives on the street and is allergic to dust and has no health insurance
b
the nurse assesses a patient who sustained a scalding burn to the left dorsal surface of the hands and fingers that occurred one day ago. there is redness, swelling, and warmth. the patient has pain, decreased fine motor movements, and limited ROM. what do these findings indicate? a. stage II of inflammation b. serious infection that should be reported c. cardinal signs of inflammation d. probable inappropriate first-aid treatment
c
the patient comes to the clinic with symptoms of achy joints, rash, and malaise. which question would be the most useful in helping the hCP to make the diagnosis of serum sickness? a. "have you had fever over 101 F or chills?" b. "did you recently get bitten or stung by an insect or spider?" c. "have you been exposed to any poisonous plants, such as poison ivy?" d. "have you taken or received any new drugs within the past 7-12 days?"
d
the nurse is preparing the 9:00 am medication and sees that the patient is due for a morning dose of thalidomide. the nurse has heard of the medication but is not exactly sure why it has been prescribed for this patient. what should the nurse do? a. give the 9:00 am dose so it is not delayed and look up the drug when there is more time b. ask the patient if the medication looks familiar and why it was prescribed c. call the HCP and ask for clarification of the order and the purpose of the drug d. use a drug resource to look up information and cross-check the patient's medical hx
d
the nurse is taking a history on a patient who is scheduled to undergo diagnostic testing with use of contrast dye. which patient statement is cause for greatest concern? a. "my sister is allergic to the dye that they use for x-ray procedures. " b. "I have a lot of seasonal allergies, and they make me pretty miserable." c. "my doctor thinks I might be at risk for diabetes and high blood pressure." d. "last year I had a procedure and my face got so swollen I could not see."
d
what feature of stem cells has made them valuable to research and therapy? a. found only in fetus tissue b. possess long life span c. resistant to cancer d. pluripotency
d
what is an example of innate-native immunity? a. nurse obtains hepatitis B series before starting a new job abroad b. patient, bitten by wild rabid animal, receives four doses of rabies vaccine c. new mother decides to breastfeed her infant for first several months d. nurse has intact healthy skin on hands and healthy mucous membranes
d
which method of testing for allergies would be used if the patient wants to undergo "allergy shots"? a. T-lymphocyte count b. blood test for C1-INH c. skin biopsy d. intradermal testing
d
the nurse is working in a clinic that serves a patient population that is frequently treated with selective immunosuppressive therapy. which questions is the nurse most likely to ask when initially interviewing new patients? select all that apply. a. "are you currently pregnant or planning to try to get pregnant in the near future?" b. "are you currently being treated for any infections?" c. "have you ever had an anaphylactic reaction prescribed medication?" d. "have you ever had any genetic testing or counseling related to allergies?" e. "would you be willing to learn how to self-inject medication?" f. "have you ever been treated or diagnosed with tb?"
a, b, f
which responses are characterized as type IV delayed hypersensitivity reactions? select all that apply. a. positive purified protein derivative test for TB b. systemic lupus erythematosus c. immune thrombocytopenic purpura d. contact dermatitis e. graft rejection f. local response to insect stings
a, d, e, f
a babysitter is caring for a child who is in the presymptomatic stage of influenza A. the babysitter has never had influenza A and develops symptoms several days after caring for the child. what type of immunity will the babysitter have as a result of antibody-antigen actions? a. B cells will be sensitized to influenza A and R b. B cells will be sensitized only to influenza A c. immunity is short term because B-cell sensitization is not adaptive d. antibody-antigen B-cell action is nontransferable from child to adult
b
the nursing instructor is quizzing a nursing student about the pharmacologic action of a decongestant drug that is prescribed for the patient. what is the best response to the instructor's query? a. "this drug will prevent vasodilation and decrease secretions." b. "this drug causes vasoconstriction and reduces the swelling." c. "this drug will decrease allergens and allergic response." d. "this drug will desensitize any allergic reactions."
b
the patient has anaphylaxis. what is the major factor that is most likely to result in the patient's death? a. delay in locating intubation equipment b. delay in administering epinephrine c. inappropriately discharging the patient d. administering the wrong rescue medication
b
what is the significance of toll-like receptors (TLRs) in helping the body to fight infection? a. research shows that diseases are spread by flies through TLRs b. TLRs interact with the surface of an organism and allow recognition of nonself c. persons who have more TLRs are more likely to develop infections d. older people and immunocompromised persons will not produce TLRs
b
a patient has sustained a severe right ankle sprain, and the nurse is explaining the process of inflammation to the patient and family. which information does the nurse include in this teaching? a. because inflammation is present, treatment for infection is advised b. the inflammation response is painful but provides long-term protection c. inflammation is a specific body defense in response to the ankle injury d. symptoms of inflammation depend on the intensity and severity of the injury
d
a patient reports a runny nose with clear drainage, watery eyes, and a scratchy throat and being in close contact with several cats. which therapy does the nurse anticipatE? a. IM epinephrine and oxygen b. oral corticosteroids and avoidance education c. observation for worsening symptoms d. decongestants and intranasal steroid spray
d
a patient who had a PPD test for TB has redness and a 9 mm induration at the injection site. the nurse suspects which type of hypersensitivity reaction? a. type 1, immediate b. type II, cytotoxic c. type III, immune complex-mediated d. type IV, delayed
d
a patient who is in good health is naturally assisted in cancer prevention by which type of immunity? a. cell-mediated b. innate c. lymphokine d. humoral
a
the nurse has just received handoff reports on several patients who are being treated for hypersensitivity or autoimmune responses. Which patient is the nurse most likely to check on first? a. patient who was treated for angioedema with epinephrine and oxygen b. patient who has serum sickness and received a dose of oral diphenhydramine c. patient who had hemolytic transfusion reaction and infusion was discontinued d. patient with tissue transplant rejection awaiting transplant surgeon consult
a
the nurse is caring for a patient after a kidney transplant. which finding prompts the nurse to quickly alert the HCP about a probably hyperacute rejection? a. there is no urine output and problems occur immediately b. blood urea nitrogen and creatinine show trend for elevation c. patient reports some tenderness at the incision site d. patient has an allergic reaction to the transplant medications
a
the nurse is caring for a patient prescribed a new oral antibiotic. eosinophil and basophil levels are elevated. what is the nurse's best interpretation of this laboratory report? a. the patient may be having an allergic reaction to the antibiotic b. the patient's body is fighting off an infection c. the patient's WBCs are phagocytizing the Invasive organisms d. the patient is at high risk for pneumonia and other respiratory infections
a
the nurse is instructing a patient who has undergone an organ transplant about immunosuppressant medications. what information does the nurse include? a. all immunosuppressive medications inc. the risk of infection and cancer b. these medications will be gradually d/c c. these medications prevent infection in the transplanted organ d. IV forms are more effective than PO medications
a
the patient experienced a MI 6 mos ago during which 25% of his LV was damaged and replaced by scar tissue. which is the most likely outcome? a. the patient will lose 25% of the effectiveness of hisLV contraction b. the patient will lose 50% of his ejection fraction c. the patient will regain 25% of the effectiveness of his LV after healing d. the patient will lose 75% of his activity tolerance
a
the patient has a documented allergy to latex. which piece of common medical equipment could trigger the patient's latex allergy if special precaution are not taken to ensure a latex-free product? a. indwelling urinary catheter b. 4x4 gauze sponge c. BP cuff d. hospital meal tray
a
the patient reports a sore throat. the nurse notes that the throat is red and the tissues look swollen and inflamed. based on the concepts of general immunity and inflammatory response, what should the nurse tell the patient about immune protection? a. protection is immediate but short term and does not provide true immunity b. protection will occur with any future exposure to the same organisms c. inflammation is a specific response that protects only the throat area d. inflammation provides some protection against passing the infection to others
a
Which statement accurately explains otitis media? a. The inflammatory response is triggered by the invasion of foreign proteins. b. Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders. c. It is caused by a left shift or increase in immature neutrophils. d. Many immune system cells released into the blood have specific effects.
a The inflammatory bacterial response of otitis media is stimulated by invading foreign proteins caused by infection.Macrophages and neutrophils are involved in the process of inflammation, but otitis media is an inflammation caused by infection. It is not caused by a left shift or increase in immature neutrophil forms. The change in form is caused by infection, such as sepsis. The action of immune system cells occurs when encountering a non-self or foreign protein to neutralize, destroy, or eliminate a foreign invader. This does not cause inflammation.
When preparing a client for allergy testing, the nurse provides the client with which instruction? a. "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." b. "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." c. "Aspirin in a low dose may be taken before testing." d. "You can take antihistamine nasal sprays before testing."
a The nurse should tell the client that, "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." Systemic glucocorticoids and antihistamines are discontinued 2 weeks before the test for this reason.Nasal sprays like fluticasone propionate (Flonase) to reduce mucous membrane swelling are permitted, except for sprays that contain an antihistamine. Allergists recommend that aspirin be withheld before testing.
which cells interact int he presence of an antigen to start antibody production? select all that apply. a. B-lymphocytes b. macrophages c. neutrophils d. T-helper/inducer cells e. T-suppressor cells f. RBCs
a, b, d
what is an example of the clinical significance of the anmnestic response? a. person who had childhood measles is re-exposed as an adult but does not develop measles b. person had influenza last year and therefore decides that this year's immunization is unnecessary c. person had cancer that is in remission; response to therapy was better than expected d. person is very healthy, has few infectious illnesses, and always recovers quickly
a
which patient is most likely to undergo and benefit from plasmapheresis therapy? a. patient with drug induced hemolytic anemia who has a high risk for kidney failure b. patient with scleroderma who is not responding to first-line treatments c. patient with tissue transplant who is experiencing organ rejectin d. patient who has angioedema with an offending agent that has a long half-life
a
which statement best describes allergy or hypersensitivity? a. excessive response to the presence of an antigen b. excessive response against self-cells and cell products c. failure of the immune system to recognize self-cells as normal d. failure of the immune system to recognize foreign cells and microbial invaders
a
The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan? a. "Please report any increased redness, swelling, warmth, or pain to your health care provider." b. "Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed." c. "A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week." d. "Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions."
a Instruction on increased signs and symptoms of inflammation could reveal signs of potential infection and is most important.Although information about having blood pressure taken or having blood drawn should be included, it is not the most important instruction for postoperative day 1 discharge. Referrals are important in helping with coping but are not the most important consideration when the client is being sent home on postoperative day 1. Positioning is important but is not the priority here.
the actions of leukocytes provide the body protection against invading organisms. what are actions of leukocytes? select all that apply. a. phagocytic destruction of foreign invaders and unhealthy or abnormal cells b. lytic destruction of foreign invaders and unhealthy cells c. stimulate maturational pathway of stem cells d. production of antibodies directed against invaders e. production of cytokines that decrease specific leukocyte growth and activity f. increase growth and differentiation of platelets
a, b, d
which clinical examples are type 1 immediate hypersensitivities? select all that apply. a. goodpasture's syndrome b. hay fever c. serum sickness d. anaphylaxis e. autoimmune hemolytic anemia f. allergic asthma
b, d, f
the nurse is reviewing the lab results of a patient who has had more than one episode of angioedema. which intervention would be the most appropriate follow-up for a positive result of a C1-INH blood test? a. assessing for ACEI that can cause angioedema b. arranging for genetic counseling related to genetic deficiency and angioedema c. ensuring that the patient knows to take corticosteroid as prescribed for angioedema d. advising the patient to have annual allergy testing to predict potential triggers of angioedema
b
the nurse is reviewing the patient's laboratory results and sees that there is a left shift (bandemia). which assessment is the nurse most likely to perform? a. look for signs of bleeding, such as petechiae b. look for signs of infection and check temperature and pulse c. check for signs of anemia, such as pallor or tachycardia d. check for s/s of inflammatory response
b
Which nursing activity can the nurse delegate to a home health aide? a. Changing the dressing for a client with a low absolute neutrophil count b. Assisting with bathing for a client with chronic rejection of a liver transplant c. Teaching a client with bacterial pneumonia how to take the prescribed antibiotic d. Assessing incisional tenderness for a client who had a recent kidney transplant
b Assisting with bathing for a client with chronic rejection of a liver transplant can be delegated to the home health aide.Changing the dressing for a client with a low absolute neutrophil count requires strict sterile technique by a licensed RN and should not be delegated because of the high risk for infection. Teaching about medications and assessments is within the scope of practice of the professional RN.
A client is admitted to the hospital with suspected Goodpasture's syndrome. Which findings does the nurse expect to observe? a. Bradycardia b. Hemoptysis c. Increased urine output d. Weight gain
b Hemoptysis (bloody sputum) is a manifestation of Goodpasture's syndrome. Goodpasture's syndrome usually is not diagnosed until serious lung and kidney problems are present.Tachycardia and not bradycardia, decreased and not increased urine output, and weight loss and not weight gain are manifestations of Goodpasture's syndrome.
The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? a. "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." b. "The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." c. "It results in release of mediators, especially histamine, because of the reaction of immunoglobulin E (IgE) antibody on mast cells." d. "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."
b The best statement by the student describing type IV hypersensitivity reaction is that the reaction of sensitized T cells with antigen and release of lymphokines is a delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity).A reaction of IgG with the host cell membrane or antigen describes a type II hypersensitivity reaction. A release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells describes a type I hypersensitivity reaction. An immune complex of antigen and antibodies deposited in the walls of blood vessels describes a type III hypersensitivity reaction.
Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner? a. Older adult client with a history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 150,000 mm3 (15.5 × 109/L), segmented neutrophils (segs) (8.0 × 109/L), bands 5% (0.5 × 109/L), lungs with slight crackles in bases, able to assist with activities of daily living, and afebrile b. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9,500 mm3 (9.5 × 109/L), segs (6.0 × 109/L), bands 1.0% (0.1 × 109/L), oxygen saturation of 93% on room air, and afebrile c. Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, WBC count 20,000 mm3 (20.0 × 109/L), segs (7.0 × 109/L), bands 10.0% (1.1 × 109/L), oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4°F (38°C) d. Older adult client with recent history of right hip replacement, with productive cough, WBC count 3,400 mm3 (3.4 × 109/L), segs (6.2 × 109/L), bands 5% (0.5 × 109/L), lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile
b The client most ready for discharge is the middle-aged client with history of multiple sclerosis because the complete blood count (CBC) is within normal limits.The older adult client with a history of congestive heart failure and elevated WBC and segs and slight crackles in lung bases is not ready for discharge. The young adult client with crackles in all lung lobes is not ready for discharge because of elevated WBCs, left shift, and febrile status. The older adult client with recent history of right hip replacement is not ready for discharge because the WBC is below normal even though the other parts of the differential are within normal limits. This client may have a viral infection with crackles in the lungs and low oxygen saturation.
Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection? a. Older adult with Parkinson disease receiving a donation from an identical twin b. Grand multipara female with a history of subsequent blood transfusions c. Middle-aged man with a 20-pack-year history d. Young adult with type 1 diabetes
b The grand multipara female with a history of subsequent blood transfusions should be assessed first because multiple pregnancies and blood transfusions greatly increase the risk of a hyperacute rejection. Hyperacute rejection occurs mostly in transplanted kidneys but is less common now with better HLA matching. Symptoms of rejection are apparent within minutes of attachment of the donated organ to the recipient's blood supply. The process usually cannot be stopped once it has started, and the rejected organ must be removed as soon as hyperacute rejection is diagnosed.The older adult with Parkinson disease receiving a donation from an identical twin has less chance of hyperacute rejection because his donor is an identical twin. Smoking places the middle-aged man with a 20-pack-year history at higher risk for postoperative respiratory difficulties, but not for hyperacute rejection. Type 1 diabetes requires close postoperative monitoring of blood sugar, but does not predispose the client to a hyperacute rejection.
when an injury or invasion occurs, phagocytosis involves seven steps. degradation is the final (7th) step. place the first six steps that precede degradation in the correct order. __ a. adherence __ b. exposure and invasion __ c. phagosome formation __ d. cellular ingestion __ e. attraction __ f. recognition
b, e, a, f, d, c
A client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client's discharge teaching plan? a. Wash fruits and vegetables with mild soap and water before eating. b. Intermittent exposure to known allergens will produce immunity. c. Remove cloth drapes, carpeting, and upholstered furniture. d. Be cautious when eating unprocessed honey.
c The most important discharge instruction to give this client is to remove cloth drapes, carpet, and upholstery in order to reduce airborne pollen, dust mites, and mold.Washing fruits and vegetables pertains to food allergies. Clients do not develop immunity to known allergens by direct intermittent exposure. Some common interventions include avoidance therapy, desensitization therapy, and symptomatic therapy. Honey is said to help some people with allergies to pollen only; it does not have an impact on airborne allergens.
a patient is admitted to the hospital for acute rejection of a kidney transplant that was preformed 2 mos ago. which intervention is appropriate for this patient? a. immediate removal of the transplanted kidney b. grief and loss counseling to prepare for loss of organ c. MRI of organ d. organ biopsy to diagnose impaired function
d
which findings are the most likely to manifest in a patient who is experiencing the release of histamine and kinins by basophils? a. fever and tachycardia b. foul odor and pus c. SOB d. swelling and edema
d
Which statement best exemplifies a client's protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos? a. Cytotoxic and cytolytic T cells destroy cells that contain the major histocompatibility complex of a processed antigen. b. Helper and inducer T cells recognize self cells versus non-self cells and secrete lymphokines that can enhance the activity of white blood cells. c. Suppressor T cells prevent hypersensitivity when a client is exposed to non-self cells or to proteins. d. Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1.
d After exposure to asbestos, a client's protection from cancer depends on a balance between helper and inducer T cells and suppressor T cells. This balance occurs when helper and inducer T cells outnumber suppressor T cells by a ratio of 2:1.The activity of cytotoxic and cytolytic T cells is most effective against self cells infected by parasites. Overreactions can cause tissue damage if an imbalance exists between helper and inducer T cells. When suppressor T cells are increased, immune function is suppressed and the client is at risk for infection.
The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? a. "I must wear a medical alert bracelet stating that I am allergic to bee stings." b. "I need to carry epinephrine with me." c. "My spouse must learn how to give me an injection." d. "I am immune to bee stings now that I have had a reaction."
d More teaching is needed if the client states, "I am immune to bee stings now that I have had a reaction." No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe.The client should carry epinephrine (EpiPen) at all times and always wear a medical alert bracelet that states all allergies. Someone (spouse, neighbor, or family member) must learn how to give the client an injection in case the client is unable to self-administer the injection.
The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client's health care provider if the client has which condition? a. Cataracts b. Crohn's disease c. Diabetes mellitus d. Hypertension
d The health care professional should be notified if the client has hypertension because decongestants have actions similar to adrenergic drugs, causing vasoconstriction and increasing blood pressure.Decongestants are not contraindicated in clients with cataracts, Crohn's disease, or diabetes mellitus.
Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? a. Plan the schedule for desensitization therapy for a client with allergies. b. Monitor the client who has just received skin testing for signs of anaphylaxis. c. Educate a client with a latex allergy about other substances with cross-sensitivity to latex. d. Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.
d The most appropriate action for the allergy clinic nurse to delegate to a nursing assistant is to remind the client about safety policies. This is within the scope of practice of a nursing assistant.Planning care and assessing for complications require broader education and scope of practice and should be done by the registered nurse. Client education is a registered nursing responsibility, requiring broader education and scope of practice.
An alert, middle-aged client is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the "ABCs" for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? a. Raise the lower extremities. b. Start intravenous (IV) administration of normal saline. c. Reassure the client that appropriate interventions are being instituted. d. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.
d The most immediate priority is for the nurse to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Assessing respiratory status is the most important assessment priority.Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.
The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed? a. Cromolyn sodium (Nasalcrom) b. Desloratadine (Clarinex) c. Fexofenadine (Allegra) d. Zafirlukast (Accolate)
d The nurse anticipates that zafirlukast (Accolate) will be prescribed. Zafirlukast is a leukotriene receptor antagonist; it works by blocking the leukotriene receptor and is used to prevent allergic rhinitis.Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug. Desloratadine (Clarinex) and fexofenadine (Allegra) are nonsedating antihistamines.
A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? a. Anxiety b. Urticaria c. Pruritus d. Stridor
d The symptom that requires the most immediate action by the nurse is stridor which indicates airway involvement and warrants immediate intervention, such as use of oxygen and administration of epinephrine. Maintaining the client's airway is the highest priority.Anxiety, urticaria, and pruritus may be symptoms of a reaction, but are not the nurse's highest priority when the client is in respiratory distress.
Which home health nurse should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? a. RN who has worked for the home health agency for 5 years in maternal-child health b. RN who has extensive critical care nursing experience and has worked in home health for a year c. RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit d. RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency
d The RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency has the experience and understanding of the needs of a posttransplantation client, as well as knowledge of cyclosporine, and would be the best choice.An RN who has worked for the home health agency for 5 years in maternal-child health, an RN who has extensive critical care nursing experience and has worked in home health for a year, and an RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit would not have specific knowledge and information on the care provided and medications used in posttransplantation clients.
A complete blood count with differential is performed on a client with chronic sinusitis. Which finding does the nurse expect? a. Segmented neutrophils, 62% b. Lymphocytes, 28% c. Bands, 5% d. Basophils, 4%
d The normal count for basophils (basos) is 0.5%; an elevated count indicates inflammation. This is common with chronic sinusitis.62% is a normal segmented neutrophil and refers to mature neutrophils, which, along with macrophages, eliminate invaders (infection) by phagocytosis. For lymphocytes, 28% is a normal count in the differential. For bands, 4% is a normal count. Bands are elevated only when an infection is present and the bone marrow cannot keep up with mature segmented neutrophils.
