Adult Health - 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 received a blood transfusion?"

A client with lupus erythematosus wants to know why autoimmune disorders are much more common in women. What is the best response by the nurse?

"Estrogen tends to enhance immunity." -Autoimmune disorders are more common in women because estrogen tends to enhance immunity. Autoimmune disorders reflect an over-functioning immune system. Androgen tends to be immunosuppressive, which would not lead to an autoimmune disorder.

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."

The nurse is caring for an elderly client with a respiratory infection. While reviewing age-related changes in the immune system, the nurse identifies which factor as having contributed to this client's infection?

Impaired ciliary action as a result of exposure to environmental toxins

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.

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 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." -Tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral cavity, they can become infected and locally inflamed

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

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

An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate wound healing and prevent poor outcomes for this client? Select all that apply.

- Nutritional status - Caloric intake - Quality of food ingested

The nurse is preparing an educational tool on the importance of nutrition and the immune system. The nurse will educate clients about the ability of which types of foods to boost immune function? Select all that apply.

- Organ meats - Beans

A client who has developed kidney failure is discussing options with the health care provider for treatment. What does the nurse understand that kidney failure is associated with?

A deficiency in circulating lymphocytes

The nurse is caring for a client with renal failure. Which factor indicates a compromised immune system?

A deficiency of circulating lymphocytes

A nurse is working in a pediatric clinic. After the nurse gives a hepatitis B immunization to an infant, the parent asks what kind of protection this provides for the child. What is the nurse's best response?

Active acquired immunity, which lasts many years or a lifetime

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. -Anaphylaxis is a rapid and profound type I hypersensitivity response. A massive release of histamine causes vasodilation; increased capillary permeability; angioneurotic edema (acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs); hypotension; and bronchoconstriction. A nurse must administer 0.2 mg of epinephrine subcutaneously to a client experiencing a severe allergic reaction.

While taking the health history of a newly admitted client, the nurse asks for a list of the client's current medications. Which of the following medication classifications would place the client at risk for impaired immune function?

Antimetabolites

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

Activation of a natural immunity response is enhanced by physical and chemical barriers. Which of the following is a physical barrier, which the nurse knows can be altered by illness, nutrition, or lifestyle?

Cilia of the respiratory tract

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?

Corticosteroids

A patient who suffered severe partial thickness burns to the face and trunk is at risk for depletion of essential proteins and immunoglobulins. The stressors associated with this patient's major injury have caused what immune process to occur?

Cortisol is released from the adrenal cortex, which contributes to immunosuppression.

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.

Cytotoxic T cell -The cytotoxic T cells (also known as killer T cells) attack the antigen directly and release cytotoxic enzymes and cytokines.

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) -Colony-stimulating factors are cytokines that prompt the bone marrow to produce, mature, and promote the functions of blood cells. CSFs enable stem cells in bone marrow to differentiate into specific types of cells such as leukocytes, erythrocytes, and platelets. Pharmacologic preparation of CSFs, such as epoetin alfa (Epogen), is used to promote the natural production of blood cells in people whose own hematopoietic functions have become compromised.

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.

An elderly client is diagnosed with cancer. While reviewing age-related changes in the immune system, what does the nurse identify as having contributed to this client's condition?

Failure of lymphocytes to recognize mutant cells

T-cells can be either regulator T cells or effector T cells. Regulator T cells are made up of helper and suppressor cells. What function are helper T-cells important in?

Fighting infection

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 -IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reactions. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.

Which immunoglobulin assumes a major role in bloodborne and tissue infections?

IgG

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 -IgG composes 75% of total immunoglobulin. It appears in serum and tissues, assumes a major role in bloodborne and tissue infections, and crosses the placenta.

A nurse is taking the health history of a newly admitted client and asks for a list of the client's current medications. Which medication classification would NOT place the client at risk for impaired immune function?

Inotropics

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 -The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

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

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

What type of cytokine will attract neutrophils and monocytes to remove debris?

Lymphokines

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

Natural immunity -Natural immunity, which is nonspecific, provides a broad spectrum of defense against and resistance to infection. It is considered the first line of host defense following antigen exposure, because it protects the host without remembering prior contact with an infectious agent.

Which type of cell is capable of recognizing and killing infected or stressed cells and producing cytokines?

Natural killer cells

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Natural killer cells -Natural killer cells are lymphocyte-like cells that circulate throughout the body looking for virus-infected cells and cancer cells. Cytokines are chemical messengers released by lymphocytes, monocytes, and macrophages. Interleukins carry messages between leukocytes and tissues that form blood cells. Interferons are chemicals that primarily protect cells from viral infections.

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 -Immunity to measles that develops after the initial infection is an example of naturally acquired active immunity. Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated toxin), whereas passive immunity develops when ready-made antibodies are given to a susceptible client.

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

Nonsteroidal anti-inflammatory drugs in large doses -Nonsteroidal anti-inflammatory drugs (NSAIDs), in large doses, inhibit prostaglandin synthesis or release. NSAIDs include aspirin and ibuprofen. Antibiotics in large doses are known to cause bone marrow suppression. Adrenal corticosteroids and antineoplastic agents are known to cause immunosuppression.

A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles?

Phagocytosis

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.

The nurse is caring for a client with a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?

Protein electrophoresis

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

Renal function decreases

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

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.

A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following?

The client's immune system cannot mount a response to the skin test.

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

A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder?

The immune system recognizes one's own tissues as "foreign."

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.

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

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 nursing instructor is discussing the development of human immunodeficiency disease (HIV) with the students. What should the instructor inform the class about helper T cells?

They are activated on recognition of antigens and stimulate the rest of the immune system.

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.

A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this client for which reason?

Use of anti-rejection drugs

The spleen acts as an emergency reservoir of

blood and removes blood and bacteria, not the tonsils.

Immunocompetence is the ability of the immune system to cooperatively protect a person from external invaders and the body's own altered cells. Immunocompetence is maintained by white blood cells and:

lymphoid tissue.

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

naturally acquired active immunity

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?

"It's believed to be caused by the differences in the sex hormones."

The nurse is reviewing the client's medications. What antihistamines are contraindicated for a client with narrow-angle glaucoma? Select all that apply.

- diphenhydramine - loratadine - cetirizine - brompheniramine

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

- infectious cells - foreign cells - cancerous cells

A client has breast cancer. The nurse is concerned about a compromised immune system in this client for which reason?

Antineoplastic drug therapy -Clients who receive chemotherapy are immunosuppressed. Antineoplastic drugs cause a compromised immune system.

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 -Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and by releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other lymphocytes and white blood cells. These cells then assist in destroying the invading organism.

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 -Interferons are used to treat immune-related disorders (e.g., multiple sclerosis) and chronic inflammatory conditions (e.g., chronic hepatitis).

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 parent has brought a child to the clinic for a wellness check. While talking with the nurse, the parent asks the nurse to suggest a diet that will maximize the immune function of growing children. What dietary pattern should the nurse suggest?

Moderate diet that is balanced and varied

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

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?

Neutrophils -Neutrophils (polymorphonuclear leukocytes [PMNs]) are the first cells to arrive at the site where inflammation occurs. Eosinophils and basophils, other types of granulocytes, increase in number during allergic reactions and stress responses.

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 -Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific micro organism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid.

Which adverse effect should the nurse closely monitor in a client who takes immunosuppressive drugs?

Respiratory or urinary system infections

Which stage of the immune response occurs when the differentiated lymphocytes function in either a humoral or a cellular capacity?

Response stage -In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. Recognition of antigens as foreign or non-self by the immune system is the initiating event in any immune response. In the proliferation stage, the circulating lymphocytes containing the antigenic message return to the nearest lymph node. In the effector stage, either the antibody of the humoral response of the cytotoxic T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader.

The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?

Serum, which depletes the body's store of immunoglobulins

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 -Vaccines are less effective in an older adult than in a younger adult because the activity of the immune system declines with the aging process. The lifestyle or gender of the client does not have great implications on the effectiveness of a vaccine.

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

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

neutrophils and monocytes. -Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.

A client is diagnosed with an immune system disorder caused by a congenital alteration in the proper development of immune cells. The nurse is aware that this immune system disorder is classified as which type?

primary immune deficiency

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 cell-mediated response occurs when T cells survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. An example of a cell-mediated response is one that occurs when an organ is transplanted. The complement system cooperates with antibodies to attract phagocytes and coat antigens to make them more recognizable for phagocytosis and stimulate inflammation and is not related to the surgery. Colony-stimulating factors prompt the bone marrow to produce, mature, and promote the functions of blood cells. Naturally acquired active immunity is a direct result of infection by a specific microorganism.

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.

Which of the following is a medical condition that is an example of a humoral immune response?

Asthma

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. -One function of the spleen is to remove bacteria from circulation; therefore, the client will be more susceptible to infection.

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?

Ataxia -Ataxia should be assessed when immune dysfunction in the neurosensory system is suspected. Hematuria, discharge, and frequency of and burning upon urination are associated with the genitourinary system.

A client is diagnosed with rheumatoid arthritis. When teaching the client and family about rheumatoid arthritis, the nurse should provide which information?

Autoimmune disorders include connective tissue (collagen) disorders.

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

B lymphocytes -B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.

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 client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse of having 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 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

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

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.

The nurse is caring for a female patient who has an exacerbation of lupus erythematosus. What does the nurse understand is the reason that females tend to develop autoimmune disorders more frequently than men?

Estrogen tends to enhance immunity.

A 38-year-old 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. Which is the most important factor related to the client's assessment?

Use of other drugs

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