Chapter 31: Assessment of Immune Function
An infection control nurse is presenting an inservice reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining? A) Agglutination B) Cellular immune response C) Humoral response D) Phagocytic immune response
A) Agglutination Rationale: Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link between two antigens. This takes place within the context of the humoral immune response, but is not synonymous with it. Cellular immune response, the immune system's third line of defense, involves the attack of pathogens by T-cells. The phagocytic immune response, or immune response, is the system's first line of defense, involving white blood cells that have the ability to ingest foreign particles.
A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of her last tetanus shot, which is over 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what? A) Antibodies B) Antigens C) Cytokines D) Phagocytes
A) Antibodies Rationale: Immunizations activate the humoral immune response, culminating in antibody production. Antigens are the substances that induce the production of antibodies. Cytokines are nonantibody proteins secreted by helper T cells that act as intercellular mediators, as in the generation of immune response. They attract and activate B cells, cytotoxic T cells, natural killer cells, macrophages, and other cells of the immune system. Phagocytes are white blood cells that engulf, ingest, and destroy foreign bodies or toxins. Immunizations do not prompt cytokine or phagocyte production.
A patient has undergone treatment for septic shock and received high doses of numerous antibiotics during the course of treatment. When planning the patients subsequent care, the nurse should be aware of what potential effect on the patients immune function? A) Bone marrow suppression B) Uncontrolled apoptosis C) Thymus atrophy D) Lymphoma
A) Bone marrow suppression Rationale: Large doses of antibiotics can precipitate bone marrow suppression, affecting immune function. Uncontrolled apoptosis, or programmed cell death, is not known to be an effect of antibiotic therapy. Inhibition of prostaglandin synthesis or release can be an effect of nonsteroidal anti-inflammatory drugs but is not typically an effect of antibiotic therapy. Immunosuppression can be an effect of adrenal corticosteroids, antineoplastic agents, and antimetabolites, but is not typically an effect of antibiotic therapy.
A patients exposure to which of the following microorganisms is most likely to trigger a cellular response? A) Herpes simplex B) Staphylococcus aureus C) Pseudomonas aeruginosa D) Beta hemolytic Streptococcus
A) Herpes simplex Rationale: Viral, rather than bacterial, antigens induce a cellular response. Herpes simplex is a virus. Staphylococcus aureus, Pseudomonas aeruginosa, and beta-hemolytic Streptococcus are all bacteria.
A patient with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the patient for which of the following complications of therapy? A) Immunosuppression B) Agranulocytosis C) Anemia D) Thrombocytopenia
A) Immunosuppression Rationale: Corticosteroids, such as prednisone, can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts. Agranulocytosis, which is a decrease in granulocytes, a type of white blood cell, may be caused by antibiotics, antithyroid drugs, or nonsteroidal anti-inflammatory drugs. Anemia, which is a decrease in red blood cells, may be caused by antibiotics or nonsteroidal anti-inflammatory drugs. Thrombocytopenia, which is a decrease in platelets, may be caused by antibiotics
1. A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact that her bone marrow is unable to produce a sufficient amount of what? A) Lymphocytes B) Cytoblasts C) Antibodies D) Capillaries
A) Lymphocytes Rationale: The white blood cells involved in immunity (including lymphocytes) are produced in the bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels.
The nurse is providing care for a patient who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment? A) Stem cell transplantation B) Serial immunizations C) Immunosuppression D) Genetic engineering
A) Stem cell transplantation Rationale: Clinical trials using stem cells are underway in clients with a variety of disorders having an autoimmune component, including multiple sclerosis. Immunizations and genetic engineering are not used to treat multiple sclerosis. Immunosuppression would exacerbate symptoms of MS
During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess? A) Acquired immunity B) Natural immunity C) Phagocytic immunity D) Humoral immunity
A) Acquired immunity
A patient requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this patient most likely has what type of immune disorder? A) A primary immune deficiency B) A gammopathy C) An autoimmune disorder D) A rheumatic disorder
ANS: A Rationale: Primary immune deficiency results from improper development of immune cells or tissues. These disorders are usually congenital or inherited
31. A client is vigilant in self-care but is frustrated by a recent history of upper respiratory infections and influenza. Which aspects of the client's lifestyle may have a negative effect on immune response? Select all that apply. A. Exercises at the gym twice a day B. Does not consume any red meat C. Takes over-the-counter daily vitamins D. Sleeps approximately seven hours daily E. Works as a medical researcher
ANS: A, E Rationale: Rigorous or competitive exercise—usually considered a positive lifestyle factor—can be a physiologic stressor and cause negative effects on immune response. Occupational or residential exposure to environmental radiation and pollutants has been associated with impaired immune function. Research jobs are among those with a higher risk of workplace pollution. Taking a multivitamin daily and not eating red meat are generally positive steps as long as the client does not rely solely on the vitamin to provide all nutrients and has the appropriate level of protein intake. Seven to nine hours of sleep daily are the general recommendations for good health and an effective immune system.
16. A client with hepatitis B has been admitted to the medical intensive care unit with sepsis. Which immunity function was most likely compromised? A. Lymphatic system B. Passive immunity C. Complement system D. Monoclonal antibodies
ANS: C Rationale: Circulating plasma proteins, known as complement, are made in the liver and activated when an antibody connects with an antigen. An impaired function of the liver caused by hepatitis B could result in the body being unable to fight a bacterial infection, which then results in sepsis. The complementary system is a natural immunity response.
32. A nurse educator is developing a care plan concerning a risk of infection related to vascular insufficiency. Which disease and/or injury would most likely align with this nursing care plan? A. Transient ischemic attack (TIA) B. Major burns C. Chronic obstructive pulmonary disease (COPD) D. Diabetes
ANS: D Rationale: In diabetes. an increased incidence of infection has been associated with vascular insufficiency, neuropathy, and poor control of serum glucose levels. Recurrent respiratory tract infections are associated with COPD, so the risk of infection is more likely related to altered inspiratory and expiratory function and ineffective airway clearance. Major burns compromise the body's first line of defense, which is the skin. The risk of infection is related to skin integrity for burns. And clients with TIA are at risk for infection, typically from stroke-associated pneumonia
A nurse has administered a childs scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following? A) Natural immunity B) Active acquired immunity C) Cellular immunity D) Mild hypersensitivity
B) Active acquired immunity Rationale: Passive/adaptive acquired immunity usually develops as a result of vaccination or contracting a disease. Natural immunity is present at birth and provides a nonspecific response to any foreign invader. Immunizations do not activate the process of cellular immunity. Cellular immunity is part of the innate/natural immunity response, which involves T cells that neutralize components of the threat within the cell itself. Hypersensitivity is infrequent, and adverse reactions (i.e., urticaria, anaphylaxis) to vaccine administration are rare
A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process? A) The cellular immune response B) Apoptosis C) Phagocytosis D) Opsonization
B) Apoptosis Rationale: Apoptosis, or programmed cell death, is the body's way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Opsonization is the coating of antigen-antibody molecules with a sticky substance to facilitate phagocytosis. The body does not use phagocytosis or the cellular immune response to remove cells from circulation.
A patient is undergoing testing to determine the overall function of her immune system. What test can be performed to evaluate the functioning of the patients cellular immune system? A) Immunoglobulin testing B) Delayed hypersensitivity skin test C) Specific antibody response D) Total serum globulin assessment
B) Delayed hypersensitivity skin test Rationale: Cellular (cell-mediated) immunity tests include the delayed hypersensitivity skin test, since this immune response is specifically dependent on the cellular immune response. Each of the other listed tests assesses functioning of the humoral immune system
A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this patient knows that the site of the injury will have an invasion of what? A) Interferons B) Phagocytic cells C) Apoptosis D) Cytokines
B) Phagocytic cells Rationale: Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken glass. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. Helper T cells are activated on recognition of antigens and stimulate the rest of the immune system. When activated, helper T cells secrete cytokines, which attract and activate B cells, cytotoxic T cells, NK cells, macrophages, and other cells of the immune system. Cytokines are the various proteins that mediate the immune response. These do not migrate to injury sites.
A patient was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response? A) Effector B) Proliferation C) Response D) Recognition
B) Proliferation Rationale: In the proliferation stage, T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. This does not occur in the response, recognition, or effector stages.
A man was scratched by an old tool and developed a virulent staphylococcus infection. In the course of the mans immune response, circulating lymphocytes containing the antigenic message returned to the nearest lymph node. During what stage of the immune response did this occur? A) Recognition stage B) Proliferation stage C) Response stage D) Effector stage
B) Proliferation stage Rationale: The recognition stage of antigens as foreign by the immune system is the initiating event in any immune response. The body must first recognize invaders as foreign before it can react to them. In the proliferation stage, the circulating lymphocyte containing the antigenic message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. In the response stage, the differentiated lymphocytes function either in a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader
A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this? A) The movement of B cells in and out of lymph nodes B) The interactions that occur between T cells and B cells C) The differentiation between different types of T cells D) The universal role of the complement system
B) The interactions that occur between T cells and B cells Rationale: T cells interact closely with B cells, indicating that humoral and cellular immune responses are not separate, unrelated processes, but rather branches of the immune response that interact. Movement of B cells does not clearly show the presence of a unified immune system. The differentiation between types of T cells and the role of the complement system does not directly suggest a single immune system.
The nurse should recognize a patients risk for impaired immune function if the patient has undergone surgical removal of which of the following? A) Thyroid gland B) Spleen C) Kidney D) Pancreas
B) spleen Rationale: A history of surgical removal of the spleen, lymph nodes, or thymus may place the client at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system
A nurse is reviewing a patients medication administration record in an effort to identify drugs that may contribute to the patients recent immunosuppression. What drug is most likely to have this effect? A) An antibiotic B) A nonsteroidal anti-inflammatory drug (NSAID) C) An antineoplastic D) An antiretroviral
C) An antineoplastic Rationale: Chemotherapy affects bone marrow function, destroying cells that contribute to an effective immune response and resulting in immunosuppression. Antibiotics in large doses cause bone marrow suppression, but antineoplastic drugs have the most pronounced immunosuppressive effect. NSAIDs and antiretrovirals do not normally have this effect.
A nurse is caring for a patient who has had a severe antigen/antibody reaction. The nurse knows that the portion of the antigen that is involved in binding with the antibody is called what? A) Antibody lock B) Antigenic sequence C) Antigenic determinant D) Antibody channel
C) Antigenic determinant Rationale: The specific area of an antigen that binds with an antibody-combining site and determines the specificity of the antigen-antibody reaction is referred to as the antigenic determinant. The T lymphocyte picks up the antigenic message, or "blueprint" of the antigen, which is the recognition of the antigen by the T lymphocyte. Agglutination is the clumping effect occurring when an antibody acts as a cross-link between two antigens. Antibody response is a type of immune response and is the immune system's second line of defense.
Diagnostic testing has revealed a deficiency in the function of a patients complement system. This patient is likely to have an impaired ability to do which of the following? A) Protecting the body against viral infection B) Marking the parameters of the immune response C) Bridging natural and acquired immunity D) Collecting immune complexes during inflammation
C) Bridging natural and acquired immunity Rationale: Complement has three major physiologic functions: defending the body against bacterial infection, bridging natural and acquired immunity, and disposing of immune complexes and the by-products associated with inflammation. Complement does not mark the parameters of the immune response; complement does not collect immune complexes during inflammation.
A patients recent diagnostic testing included a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the patients immunity? A) Humoral immune function B) Antigen recognition C) Cell-mediated immune function D) Antibody production
C) Cell-mediated immune function Rationale: A total lymphocyte count is a test used to determine cellular immune function. It is not normally used for testing humoral immune function and the associated antigen-antibody
A patient with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. What is the immune response that predominates in this situation? A) Humoral B) Nonspecific C) Cellular D) Mitigated
C) Cellular Rationale: Most immune responses to antigens involve both humoral (antibody) and cellular responses, although only one predominates. During transplantation rejection, the cellular response predominates over the humoral (antibody) response. Transplantation rejection is not associated with nonspecific immune response. Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi.
A patients current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by what cells? A) Suppressor T cells B) Memory T cells C) Cytotoxic T cells D) Complement T cells
C) Cytotoxic T cells Rationale: Cytotoxic T cells (also called CD8 + cells) participate in the destruction of foreign organisms, attacking the antigen directly by altering the cell membrane, causing cell lysis (disintegration), and releasing cytolytic enzymes and cytokines. Memory T cells are responsible for recognizing antigens from previous exposure and mounting an immune response; however, they do not participate in the direct destruction of foreign microorganisms. Suppressor T cells have the ability to decrease B-cell production, thereby keeping the immune response at a level that is compatible with health; however, they do not participate in the direct destruction of foreign microorganisms. The complement system does not exist as a type of T cell.
The nurse knows that the response of natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances the response of natural immunity? A) Cell cytoplasm B) Interstitial fluid C) Gastric secretions D) Cerebrospinal fluid
C) Gastric secretions Rationale: Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi. Not all body fluids are chemical barriers, however. Cell cytoplasm, interstitial fluid, and CSF are not normally categorized as chemical barriers to infection
A gerontologic nurse is caring for an older adult patient who has a diagnosis of pneumonia. What age-related change increases older adults susceptibility to respiratory infections? A) Atrophy of the thymus B) Bronchial stenosis C) Impaired ciliary action D) Decreased diaphragmatic muscle tone
C) Impaired ciliary action Rationale: As a consequence of impaired ciliary action due to exposure to smoke and environmental toxins, older adults are vulnerable to lung infections. This vulnerability is not the result of thymus atrophy, stenosis of the bronchi, or loss of diaphragmatic muscle tone.
A patient is responding to a microbial invasion and the patients differentiated lymphocytes have begun to function in either a humoral or a cellular capacity. During what stage of the immune response does this occur? A) The recognition stage B) The effector stage C) The response stage D) The proliferation stage
C) The response stage Rationale: In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader. In the recognition stage, the recognition of antigens as foreign, or nonself, by the immune system is the initiating event in any immune response. During the proliferation stage the circulating lymphocytes containing the antigenic message return to the nearest lymph node.
A nurse is reviewing the immune system before planning an immunocompromised patients care. How should the nurse characterize the humoral immune response? A) Specialized cells recognize and ingest cells that are recognized as foreign. B) T lymphocytes are assisted by cytokines to fight infection. C) Lymphocytesare stimulated to become cells that attack microbes directly. D) Antibodies are made by B lymphocytes in response to a specific antigen
D) Antibodies are made by B lymphocytes in response to a specific antigen Rationale: The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. Phagocytosis and direct attack on microbes occur in the context of the cellular immune response
A patient is being treated for cancer and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which of the following ways? A) Causing apoptosis of cytokines B) Increasing interferon production C) Causing CD4+ cells to mutate D) Depressing antibody response
D) Depressing antibody response Rationale: Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. This specific nutritional deficit does not cause T-cell mutation, an increase in the production of interferons, or apoptosis of cytokines.
37. A client is fighting an active infection. What function will cytokines perform in this immune response? A. Determining whether a cell is foreign B. Determining if lymphokines will be activated C. Determining whether the T cells will remain in the nodes and retain a memory of the antigen D. Determining whether the immune response will be the production of antibodies or a cell-mediated response
D) Determining whether the immune response will be the production of antibodies or a cell-mediated response Rationale: Separate subpopulations of helper T cells produce different types of cytokines and determine whether the immune response will be the production of antibodies or a cell-mediated immune response. Cytokines do not determine whether cells are foreign, determine if lymphokines will be activated, or determine the role of memory T cells.
A patient is being treated for bacterial pneumonia. In the first stages of illness, the patients dyspnea was accompanied by a high fever. Currently, the patient claims to be feeling better and is afebrile. The patient is most likely in which stage of the immune response? A) Recognition stage B) Proliferation stage C) Response stage D) Effector stage
D) Effector stage Rationale: The immune response culminates with the effector stage, during which offending microorganisms are killed by the various actions of the immune system. The client's improvement in health status is likely the result of this final stage in the immune response
A neonate exhibited some preliminary signs of infection, but the infants condition resolved spontaneously prior to discharge home from the hospital. This infants recovery was most likely due to what type of immunity? A) Cytokine immunity B) Specific immunity C) Active acquired immunity D) Nonspecific immunity
D) Nonspecific immunity Rationale: Natural immunity, or nonspecific immunity, is present at birth. Active acquired or specific immunity develops after birth. Cytokines are proteins that mediate the immune response; they are not a type of immunity
The nurse is completing a focused assessment addressing a patients immune function. What should the nurse prioritize in the physical assessment? A) Percussion of the patients abdomen B) Palpation of the patients liver C) Auscultation of the patients apical heart rate D) Palpation of the patients lymph nodes
D) Palpation of the patients lymph nodes
A nurse has admitted a patient who has been diagnosed with urosepsis. What immune response predominates in sepsis? A) Mitigated B) Nonspecific C) Cellular D) Humoral
D) humoral Rationale: Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. For example, during transplantation rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant role. Neither mitigated nor nonspecific cell response is predominant in this situation
A patients injury has initiated an immune response that involves inflammation. What are the first cells to arrive at a site of inflammation? A) Eosinophils B) Red blood cells C) Lymphocytes D) Neutrophils
D) neutrophils Rationale: Neutrophils are the first cells to arrive at the site where inflammation occurs. Eosinophils increase in number during allergic reactions and stress responses, but are not always present during inflammation. RBCs do not migrate during an immune response. Lymphocytes become active but do not migrate to the site of inflammation.
14. A nurse is planning a client's care and is relating it to normal immune response. During which stage of the immune response do sensitized lymphocytes stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate? A. Recognition stage B. Proliferation stage C. Response stage D. Effector stage
D) proliferation stage Rationale: In the proliferation stage, the circulating lymphocytes containing the antigenic message return to the nearest lymph node. Once in the node, these sensitized lymphocytes stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate. T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. This does not take place during the three preceding stages. During the recognition stage, which is the initial stage of the immune response, lymphocytes recognize antigens as foreign, or non-self. In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. This stage begins with the production of antibodies by the B lymphocytes in response to a specific antigen. The cellular response stimulates the resident lymphocytes to become cells that attack microbes directly rather than through the action of antibodies. These transformed lymphocytes are known as cytotoxic (killer) T cells. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader. The coupling initiates a series of events that in most instances results in total destruction of the invading microbes or the complete neutralization of the toxin
A nurse is planning the assessment of a patient who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among what group? A) Young adults B) Native Americans C) Women D) Hispanics
c) women Rationale: Many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones. Sex hormones play definitive roles in lymphocyte maturation, activation, and synthesis of antibodies and cytokines. Autoimmune disorders in women, such as lupus and multiple sclerosis, may be linked to hormonal changes that can occur during puberty, pregnancy, and menopause. Young adults, Native Americans/First Nations and people of Hispanic descent are not known to have a higher incidence or prevalence of autoimmune disorders