Lymphatic system and immunity
The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level?
Decreased oxygen level.
A client presents to the clinic with reports of itching and hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?
Diphenhydramine
A client is scheduled for diagnostic skin testing in 1 week. What should the nurse be sure to instruct the client prior to the scheduled appointment?
Do not take prescribed or over-the-counter antihistamines or cold preparations for at least 72 hours before testing.
Painless enlargement of one or more lymph nodes, weight loss, fatigue, night sweats, pruritus and marked anemia are symptoms of
Hodgkin's disease
A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?
How to apply an elastic sleeve or stocking
An antiviral factor that interferes with viral replication in mammalian cells, they stimulates the infected cells and those nearby to produce proteins that prevent the virus from replicating within them.
Interferons
A young client has just been diagnosed with lymphoma. The client asks the nurse what a lymphoma is. What would be the nurse's best answer?
It is a group of cancers that affect the lymphatic system.
A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
Listen and show interest as the client expresses feelings.
Which term refers to a form of white blood cell involved in immune response?
Lymphocyte
What is the largest source of public funding for HIV/AIDS care
Medicaid
A client will be starting on antiretroviral therapy, and is concerned about being able to afford the therapy. The nurse can inform the client that the largest source of public funding for HIV/AIDS care is:
Medicaid.
The clinic nurse is caring for a client with an allergic disorder who has received the first sensitizing dose of a new drug. What nursing action is most important at this point?
Monitor the client for reactions.
The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer 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
What are the 3 types of immunity
Naturally acquired immunity, artificially acquired active immunity and passive immunity
The nurse is caring for a client newly admitted to the unit with a diagnosis of lymphangitis. What interventions would the nurse institute to help promote the resolution of the lymphangitis? Select all that apply.
Note response to antibiotic therapy, Encourage independent activities of daily living, Elevate the area, Apply warm soaks/compresses to the area.
The client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client experiences nausea. What measures should the nurse suggest to help the client reduce the feeling of nausea?
Offer clear liquids such as carbonated beverages, water, and ice pops.
What is the function of the thymus gland?
Programs T lymphocytes to become regulator or effector T cells
The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?
Progressive tissue damage without any verifiable etiology
What is the third largest source of funding for HIV
Ryan white program
Lymphangitis and lymphadenitis is commonly caused by what microorganism
Streptococcal
A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?
"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."
A client comes to the clinic and reports having "broken out in hives and itching since eating strawberries this morning." The client states never having had problems with strawberries before. What is the best response by the nurse?
"It is possible to develop an allergic reaction to something you have had prior exposure to previously."
A client calls the clinic and informs the nurse of having a significant other diagnosed with infectious mononucleosis, wanting to know how long it will be before the client gets it. What does the nurse inform the client that the incubation period is for infectious mononucleosis?
30 to 50 days
Incubation person for Mono
30 to 50 days
The nurse is caring for a group of clients. Which client does the nurse suspect is most likely to have mononucleosis?
A 19-year-old college student with cervical node enlargement and fever
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self."
A client has developed an infection that resulted in lymphangitis. What does the nurse suspect the causative organism is that caused the infection?
A streptococcal microorganism
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?
Airway obstruction
A client had a left radical mastectomy with an axillary node dissection 6 months ago and is having a large amount of edema in the left arm down to the fingers. What should the nurse inform the client is the reason for the edema?
An accumulation of lymphatic fluid that results from impaired lymph circulation.
The nurse is evaluating a client's readiness for allergy skin testing. The nurse determines that the testing will need to be postponed when it is revealed that the client took which classification of medication the night before?
Antihistamine
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
Apply an allergy bracelet and flag the chart.
A client has just been admitted to the unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?
Are you experiencing fever, chills, or night sweats?
Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and the client's lifestyle during the interview process?
To determine if the client has practices that the client at risk for acquired immunodeficiency syndrome (AIDS)
A client who is HIV/AIDS positive has orders for laboratory tests to be performed. What precautions should the nurse observe whenever there is a risk of exposure to the blood and body fluids of an infected client?
Transport the specimens of body fluids in leak-proof containers.
The nurse is caring for the client with infectious mononucleosis that has inflammation of the pharyngeal mucosa. What foods or liquids would be best to offer to this client?
Vanilla pudding and iced tea
What is the cause of lymphedema
accumulation of lymph containing a large % of protein within lymphatic vessels
When does Artificially acquired active immunity result
after a vaccination
What is the best place for a prick or scratch test
back, each scratch must be 3 to 5 cm apart
Autologous blood
blood donated by and stored for a patient for future personal use
Where are WBCs manufactured and found
bone marrow, found in blood and lymph tissue
Allergic disorder
characterized by a hyperimmune response to weak antigens that are usually harmless
How is mono spread
direct contact with saliva and pharyngeal secretions from an infected person.
Natural acquired active immunity occurs when?
direct result of an infection
Tx for lymphedema
elevation, compression garments, complex decongestive physiotherapy, mechanical pulsating compression device
Treatment of lymphadenitis
elevation, warmth, elastic sleeve or stocking
Antineoplastic medication
help with immunosuppressant effect, helps the immune system do a better job of identifying cancer cells so it can attack and kill them
Lymphadenitits
inflammation affecting lymph nodes
Lymphangitis
inflammation of lymphatic vessles
Signs and symptoms of Non- Hodgkins
lymph node enlargement occurs cervical, axillary and inguinal
A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action?
maintaining an open airway
AIDs dementia complex
neuro condition causes degeneration of the brain, affects mood, cognition and motor functions
What must client avoid before allergy skin testing
over the counter antihistamines or cold preparations for at least 48-72 hours
How to assess for lymph disorders
palpate lymph notes in neck for tenderness/swelling note size, location and characteristics of symptomatic lymph nodes.
What is a prick or scratch test
pricking or scratching the skin and applying a small amount of liquid test antigen to the scratch- allergy testing
What is the function of the thymus
produces lymphocytes during fetal development, after birth programs T lymphocytes to become regulator or effector T cells
Passive immunity develops when
ready made antibodies are given to a susceptible person no memory cells are produced, only last several weeks to few months
What kind of diet is recommended to patient with mono
soft bland foods, cool liquids, gargling with warm salt water
What is an example of a cell mediated response
the response when an organ is transplanted
Signs and symptoms of autoimmune disorders
unrelenting progressive tissue damage without any verifiable etiology
Safe sex practices
use a condom with spermicide that contains nonoxynol 9
What is a cell mediated response
when Tcells survey proteins in the body, actively analyze surface features and respond to those that differ by attacking.
Who is susceptible to mono
young adults living in close quarters like college students, armed service members
A client tells the nurse, "You know I have AIDS. I still cannot afford to tell my employer because they will probably cancel my health insurance, then what would I do?" What is the best response by the nurse?
"An employer cannot cancel your currently active health insurance on the basis of AIDS."
A client requires a blood transfusion for anemia and tells the nurse, "I don't want a transfusion because I don't want to get AIDS." Which is the best response from the nurse to the client?
"The blood is screened very carefully; the risk is approximately 1 in 2 million.
A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse?
"These tissues filter bacteria from tissue fluid."
A client is considering beginning sexual relations and wants to know the best way to be protected from a sexually transmitted infection and HIV. What is the best response by the nurse?
"Using a latex condom and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV."
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 bone marrow."
When an attenuated toxin is administered to a client, the B-cell lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this?
Artificially acquired active immunity
Disorder when killer T cells and autoantibodies attack or destroy natural cells.
Autoimmune disorders
A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?
Bank autologous blood.
Fluids HIV is transmitted in
Blood, semen, vaginal secretions and breast milk
Name first generation Antihistamines
Brompheniramine, chlorpheniramine, clemastine, diphenhydramine, promethazine
Diagnostic testing for an immune disorder on initial exam
CBC with diff
How can we reduce nausea caused by chemotherapy
Clear liquids, carbonated beverages, water and ice pops
A client who is a teenager has been brought to the clinic by the parent and is suspected of having an immune system disorder. What tests would the nurse expect to be ordered for this young client?
Complete blood count with differential
Other than abstinence, what is the only proven method of decreasing the risk of sexual transmission of HIV infection?
Consistent and correct use of condoms
A type of protein that is made by certain immune and non immune cells and has an effect on the immune system
Cytokines
The nurse is caring for a client diagnosed with infectious mononucleosis who is having trouble eating. What would the nurse advise this client to improve his oral intake?
Eat soft, bland foods and drink cool liquids.
The nurse is caring for a client with chronic fatigue syndrome. What is a realistic nursing intervention when taking care of a client with this diagnosis?
Educate the client about the disease process.
An adult client has developed lymphedema postmastectomy. What is the common method used to promote lymphatic drainage and prevent edema in all clients with lymphedema?
Elevate the affected part of the body.
The nurse is performing a physical assessment on a client with a suspected lymphatic disorder. What would be the nurse's primary assessment for all clients with lymphatic disorders?
Enlargement of the lymph glands
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?
Epoetin alfa (Epogen)
What is Epogen and what is it used for
Epoetin alfa, used to stimulate production of RBC's
Natural Killer Cells NK
Express activation receptors that recognize virus-infected cells
What is the function of the tonsils
Filter bacteria from tissue fluid
A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?
For their immunosuppressant effects
A client infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV?
Gynecologic problems
Women with HIV might have these kinds of problems
Gyno problems, abnormal PAP, genital warts, PID, persistant vaginitis
Regulate immune response
Interleukins
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?
Passive immunity transferred by the mother
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?
T-cell lymphocytes survey proteins in the body and attack the invading antigens.
The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan?
The CD4 count is the major indicator of immune function and guides therapy, Antiretroviral therapy targets different stages of the HIV life cycle.
A client on antiretroviral drug therapy informs the nurse about sometimes forgetting to take the medication for a few days. What should the nurse inform the client can occur when the medications are not taken as prescribed?
The client is risking the development of drug resistance and drug failure.
An older adult client, who leads a sedentary lifestyle, and a younger client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. The nurse knows that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?
The older client because of age
A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing?
The skin will be scratched, and a small amount of the liquid test antigen will be applied to the scratch, usually on the back.
What test will the nurse assess to determine the client's response to antiretroviral therapy?
Viral load
The nurse has four clients that come to the clinic for healthcare. Which client has the highest risk factor for HIV infection?
a 26-year-old inmate who receives tattoos in prison
What is usually used to treat lymphangitis
broad spectrum antibiotic
Lymphoma
cancer of the lymphatic system
