Chapter 31: Assessment of Immune Function
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 Feedback: Immunizations activate the humoral immune response, culminating in antibody production. Antigens are the substances that induce the production of antibodies. 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 Feedback: Large doses of antibiotics can precipitate bone marrow suppression, affecting immune function. Antibiotics are not noted to cause apoptosis, thymus atrophy, or lymphoma.
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 Feedback: Corticosteroids such as prednisone can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts.
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 Feedback: 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
A patient is vigilant in her efforts to take good care of herself but is frustrated by her recent history of upper respiratory infections and influenza. What aspect of the patients lifestyle may have a negative effect on immune response? A) The patient works out at the gym twice daily. B) The patient does not eat red meats. C) The patient takes over-the-counter dietary supplements. D) The patient sleeps approximately 6 hours each night.
A) The patient works out at the gym twice daily. Feedback: Rigorous exercise or competitive exercise usually considered a positive lifestyle factor can be a physiologic stressor and cause negative effects on immune response. The patients' habits around diet and sleep do not present obvious threats to immune function.
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 Feedback: 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 Feedback: 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 lymphocyte's 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.
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 Feedback: A history of surgical removal of the spleen, lymph nodes, or thymus may place the patient 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 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 Feedback: 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 do not directly suggest a single immune system.
The nurse is assessing a clients risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity? A) The patient takes a beta blocker for the treatment of hypertension. B) The patient is under significant psychosocial stress. C) The patient had a pulmonary embolism 18 months ago. D) The patient has a family history of breast cancer.
B) The patient is under significant psychosocial stress. Feedback: Stress is a psychoneuroimmunologic factor that is known to depress the immune response. Use of beta blockers, a family history of cancer, and a prior PE are significant assessment findings, but none represents an immediate threat to immune function.
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 Feedback: 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 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
C) An autoimmune disorder Feedback: Primary immune deficiency results from improper development of immune cells or tissues. These disorders are usually congenital or inherited. Autoimmune disorders are less likely to have a genetic component, though some have a genetic component. Overproduction of immunoglobulins is the hallmark of gammopathies. Rheumatic disorders do not normally involve impaired immune function.
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 Feedback: The portion of the antigen involved in binding with the antibody is referred to as the antigenic determinant. This portion is not known as an antibody lock, antigenic sequence, or antibody channel.
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 Feedback: 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 Feedback: Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. During transplantation rejection, the cellular response predominates over the humoral response. Neither a mitigated nor nonspecific cell response is noted in this situation.
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 Feedback: 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 Feedback: 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 nurse is admitting a patient who exhibits signs and symptoms of a nutritional deficit. Inadequate intake of what nutrient increases a patients susceptibility to infection? A) Vitamin B12 B) Unsaturated fats C) Proteins D) Complex carbohydrates
C) Proteins Feedback: 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. As a result, the patient has an increased susceptibility to infection. Low intake of fat and vitamin B12affects health, but is not noted to directly create a risk for infection. Low intake of complex carbohydrates is not noted to constitute a direct risk factor for infection.
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 Feedback: 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 non-self, 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 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 Feedback: Many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones.
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. Feedback: 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 Feedback: 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.
A nurse is planning a patients care and is relating it to normal immune response. During what stage of the immune response should the nurse know that antibodies or cytotoxic T cells combine and destroy the invading microbes? A) Recognition stage B) Proliferation stage C) Response stage D) Effector stage
D) Effector stage Feedback: 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. This does not take place during the three preceding stages.
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 Feedback: 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.
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 Feedback: During the assessment of immune function, the anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement. If palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Because of the central role of lymph nodes in the immune system, they are prioritized over the heart, liver, and abdomen, even though these would be assessed.
