Adult Health Ch. 35

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 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 is a hyperimmune response to something in the environment that is usually harmless."

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 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."

A client is informed that his white blood cell count is low and that he 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."

The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?

A 65-year-old client who had chicken pox when he was 12 years old

A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?

A cell-mediated response

A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?

Administer epinephrine.

A client developed an infection while on vacation in Central America and is now taking the antibiotic chloramphenicol. What should the client be monitored for when taking this drug?

Aplastic anemia

A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected?

Assess for ataxia using the finger-to-nose test and heel-to-shin test

Which of the following cell types are involved in humoral immunity?

B lymphocytes

While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. What strategies would have a positive effect on the immune system?

Biofeedback, relaxation, and hypnosis

A patient is being treated in the intensive care unit for sepsis related to ventilator-associated pneumonia. The patient is on large doses of three different antibiotics. What severe outcome should the nurse monitor for in the lab studies?

Bone marrow suppression

Which condition is associated with impaired immunity relating to the aging client?

Breakdown and thinning of the skin

A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?

Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.

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?

Cytotoxic T cells

A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used?

Digestive enzymes destroy its protein structure.

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?

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?

Epoetin alfa (Epogen)

Which of the following protective responses begin with the B lymphocytes?

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?

IgE

At 39 weeks' gestation, a pregnant client visits the physician for a scheduled prenatal checkup. The physician determines that the fetus has developed an infection in utero and sends the client for an emergency cesarean delivery. The client is very concerned about the health of her unborn child. Based on knowledge of the immune system, the delivery room nurse explains about which immunoglobulin that will be increased in the fetus at the time of birth and will be actively fighting the infection?

IgG

A 34-year-old client is diagnosed with chronic hepatitis C. Testing reveals that the client is a candidate for treatment. The nurse anticipates that which therapy could be used to treat the client's condition?

Interferon

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?

Lymphocyte

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:

Lymphocytes migrate to areas of the lymph node

A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?

Natural immunity

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. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?

Naturally acquired active immunity

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?

Naturally acquired active immunity

Which medication classification is known to inhibit prostaglandin synthesis or release?

Nonsteroidal anti-inflammatory drugs (in large doses)

Which type of cells destroys antigens already coated with antibody?

Null

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 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

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

In the immune response cycle, lymphocytes interfere with disease by picking up specific antigens from organisms to alter their function during which stage of an immune response?

Proliferation

A nurse is teaching a community group about healthy lifestyles. A participant asks about how to maintain a healthy immune system. The nurse informs the group that which factor will positively affect the immune system?

Strong family and community connections

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?

Surgical removal of the appendix

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.

The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?

The client appears mildly ill, listless, and disheveled.

A 64-year-old male client, who leads a sedentary life-style, and a 31-year-old female client, who has a very stressful and active life-style, require a vaccine against a particular viral disorder. As the nurse, you would know 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 male client because of his age

Which statement accurately reflects current stem cell research?

The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen.

Which of the following is accurate regarding acquired immunity? Select all that apply.

Usually develops as a result of exposure to an antigen through immunization. An immunologic response acquired during life but not present at birth. Can develop by contracting a disease.

The immune system is a complicated and intricate system that contains specialized cells and tissues that protect us from external invaders and our own altered cells. Which term is used to define any substances capable of inducing a specific immune response and of reacting with the products of that response?

antigens

What types of cells are the primary targets of the healthy immune system? Select all that apply.

cancerous cells foreign cells infectious cells

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.

The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?

interferons

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:

neutrophils and monocytes.

A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which reason?

Exposure to foreign antigens may cause altered immune function.

Which type of immunity becomes active as a result of infection by a specific microorganism?

Naturally acquired active immunity

The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?

The injection area swells if the client has developed antibodies against the antigen.

The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which statement correctly describes the process of autoimmunity?

The normal protective immune response attacks the body, damaging tissues.

A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?

The nurse ensures a written consent is obtained prior to testing.

A nurse is developing a teaching plan for a community presentation on smoking cessation. Based on current research regarding the effects of cigarette smoking on the immune system, which alterations in immune function can be attributed to smoking and should be included in the teaching presentation? Select all that apply.

Increased white blood cell count Decreased T-cell function Decreased natural killer cells Increased risk of infection

The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?

Lymphoid tissues

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?

Macrophages

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.

A client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. What is the most important factor related to the client's assessment?

The client's use of other drugs