Ch 35: Assessment of Immune Function (1)
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? pg. 1064
"It is a hyperimmune response to something in the environment that is usually harmless."
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide? pg. 1007
Artificially acquired active immunity
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
A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?
Assure the client that this is a normal reaction
Which assessment should be completed if immune dysfunction is suspected in the neurosensory system? pg. 1014
Ataxia
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? pg. 1011-1012
Cytotoxic T cells
Which of the following is an age-related change associated with the immune system? pg. 1015
Decreased antibody production
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? pg. 1018
Exposure to foreign antigens may cause altered immune function.
Which of the following protective responses begin with the B lymphocytes? pg. 1007
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? pg. 1058
IgE
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: pg. 1006
Lymphocytes migrate to areas of the lymph node
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? pg. 1006
Macrophages
The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function? pg. 1018
Previous organ transplantation
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? pg. 1018
Radiation destroys lymphocytes.
Which condition is associated with impaired immunity relating to the aging client? pg. 1015
Renal function decreases
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? pg. 1018
Serum, which depletes the body's store of immunoglobulins
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? pg. 1017
Surgical removal of the appendix
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? pg. 1007
The immune system recognizes one's own tissues as "foreign."
Chronic illnesses may contribute to immune system impairment in various ways. Renal failure is associated with pg. 1018
deficiency in circulating lymphocytes.
The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine? pg. 1819
A 65-year-old client who had chicken pox when he was 12 years old