chapter 31 assessment of immune function

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 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

a child is brought to the clinic with a rash and is subsequently diagnosed with measles. The parent reports also having had the measles as a young child. what type of 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 immunity type becomes active as a result of infection by a specific microorganism?

naturally acquired active immunity page 988

Ibuprofen affects the immune system by causing

neutropenia page 1000

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 page 989

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

neutrophils and monocytes

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

neutrophils and monocytes page 989

A nurse is exposed to hepatitis C and receives a shot of gamma globulin. What type of immunity does this nurse have?

passive immunity page 989

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 page 989

The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for immune function?

previous organ transplantation page 999

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

during which stage of the immune response does the circulating lymphocytes containing the antigenic message return to the nearest lymph node?

proliferation

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

renal function decreases page 997

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 bodys store of immunoglobulins page 1000

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 protein in the body and attack the invading antigens page 989

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 page 1001

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 page 1000

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" page 989

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 page 1001

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?" page 1000

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." page 996

A patient tells the nurse "I can't believe I have ineffective function and am getting sick again. I exercise rigorously and compete regularly." What is the best response by the nurse?

"rigorous exercise can cause negative effects on immune response." page 1001

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" page 987

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

Ataxia page 996

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 page 992

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

IgG

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells. page 993

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 page 992

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 page 1002

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

A client has has 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 page 1002

A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complains 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 page 991

Which of the following is accurate regarding acquired immunity?

an immunologic response usually develops as a result of exposure to an antigen through immunization can develop by contracting a disease page 989

the client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?

avoid antihistamines and cold preparations for 48 to 72 hours before the test page 1001

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 hyposis

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 page 1000

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

breakdown and thinning of the skin

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

A client is admitted to the hospital with a diagnosis of pneumonia. The client infomrs 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 medications do not contain substances which the client is hypersensitive page 1001

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 page 1001

The nurse is obtaining the medical history of a client with crohn's disease. What medication would the nurse include when asking what medications the client has taken for suppression of the inflammatory and immune response?

corticosteroids

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

cytotoxic T cell page 993

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

Which of the following is a age related change associated with the immune system?

decreased antibody production page 997

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

natural immunity

A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection?

through the mucous membranes of the throat page 990

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) page 998

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

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 cells 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 nurse is explaining treatment options to a client diagnosed with an immune dysfunction. Which statement by the client accurately the teaching about current stem cell research?

"stem cell transplatation has been carried out in humans with certain types of immune dysfunction, and clinical trails using stem cells are underway in clients with a variety of disorders with an autoimmune component." page 995-996

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 page 996

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

b lymphoctyes page 990

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

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. What cells should be isolated?

cytotoxic t cells 993

The nurse is completing a physical assessment with an older adult client. Which findings indicate to the nurse that the client is experiencing age related changes to the immune system?

diarrhea skin tears pain with voiding

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 school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?

engulfment and digestion of bacteria and foreign material page 989

A nurse is taking a 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

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 page 1000

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

fighting infection page 993

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses?

immunosenscence page 996

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 987

what types of cells are the primary targets of the healthy immune system?

infections cells foreign cells cancerous cells

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 show viral replication?

interferons

Proteins formed when cells are exposed to viral or foreign agents that are capable of activating other components of the immune system are referred to as

interferons page 995

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 page 995

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 nodes

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 page 987

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 page 989

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

natural killer cells

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 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

Which statement accurately reflect current stem cell research?

the stem cell is know as a precursor cell that replenishes the body's entire supply of both red and white cells page 987

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 page 987

during an annual examination, an older client tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel fine!" Based on knowledge of neoplastic disease and the aging immune system, what teaching should the nurse include in the clients plan of care?

tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by T lymphocytes; therefore the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early. the increase in occurance of autoimmune diseases with aging strongly suggests a predisposition toward various types of cancer due to the body's inability to differentiate between self and non self. Routine screening increases the chance of finding and treating cancer early. nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development.