Chapter 35 Assessment Of Immune Function
The nurse is instructing client's 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 years old -Half of individuals living to age 65 years have had or will develop shingles and may not understand the potential seriousness and risk for complications. Nurses as client advocates should determine and provide health information regarding the shingles vaccine. The other clients are not candidates for the vaccine.
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.
(see full question) A patient comes into the emergency department with complaints of difficulty walking and loss of muscle control in the arms. As the nurse begins the physical examination, which of the following 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. -Ataxia should be assessed when suspecting immune dysfunction in the neurosensory system.
Which of the following is associated with impaired immunity relating to the aging patient?
Decreased renal function. -Decreased renal circulation, filtration, absorption, and excretion contribute to the risk for UTIs. The antibody production decreases, skin become thinner, and the incidence of autoimmune disease increases with age.
The body has several mechanisms to fight disease, one of which is sending chemical messengers. Specifically, the messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger promotes inflammation, fever, and angiogenesis?
Interleukins. -Interleukins carry messages between leukocytes and tissues that form blood cells. Some interleukins enhance the immune response, whereas others suppress it (Martini & Bartholomew, 2010). Examples of interleukin activity include promotion of inflammation and fever, production of antibodies, formation of new blood vessels (known as angiogenesis), etc.
You are the clinic nurse caring for a client with a suspected diagnosis of HIV. You are preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV?
Obtain a written consent from the client. -It is important that the nurse obtain written consent from the client before performing an HIV test and keep the results of HIV test confidential. The nurse may not ask the client to avoid excess fluid intake or abstain from intercourse before the tests. The client also need not take off ornaments and metallic objects worn unless they are likely to interfere with the test results.
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
Assure the patient that this is a normal reaction. -The nurse should assure the patient that this is a normal reaction. When disease-specific antigens are injected, the injection area swells as a result of the patient developing antibodies against the antigen that is introduced. The nurse should also keep in mind that the patient is not necessarily actively infectious if the test results are positive. Rubbing the area gently or even applying ice packs may only aggravate the swelling. The swollen area should be left open to heal by itself. The nurse should await the physician's instructions before advising the patient to use any prescribed analgesics.
Which of the following protective responses begin with the B lymphocytes?
Humoral -A second protective response, the humoral immune response, begins with the B lymphocytes, which can transform themselves into plasma cells that manufacture antibodies. The first line of defense, the phagocytic immune response, involves the white blood cells (WBCs; granulocytes and macrophages), which have the ability to ingest foreign particles. The third mechanism of defense, the cellular immune response, also involves T lymphocytes, which can turn into special cytotoxic (or killer) T cells that can attack the pathogens. Recognition of antigens as foreign, or non-self, by the immune system is the initiating even in any immune response.
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 of the following reasons?
Radiation destroys lymphocytes. -Radiation destroys lymphocytes and decreases the ability to mount an effective immune response. Radiation is not associated with an excess of lymphocytes or an excess or deficiency of hemoglobin.
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. -The injection area swells if the client has developed antibodies against the antigen. The client is not necessarily actively infectious if the test results are positive. Although a productive cough is one of the symptoms of active tuberculosis, it may also indicate other diseases and disorders. The area should not be painful, and the client should not break out with a rash.
Decades ago, a typical childhood surgery, after repeated bouts with tonsillitis, was to have a tonsillectomy and adenoidectomy. That was before the role of the tonsils and adenoids were better understood. As it is understood today, what are the roles of the tonsils and adenoids?
They are lymphoid tissues that filter bacteria from tissue fluid. -The tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral and nasal passages, they can become infected and locally inflamed. The tonsils and adenoids filter bacteria from tissue fluid.
A patient arrives at the clinic and informs the nurse that she has a very sore throat as well as a fever. A rapid strep test returns a positive result and the patient is given a prescription for an antibiotic. How did the streptococcal organism gain access to the patient to cause this infection?
Through the mucous membranes of the throat. -In a streptococcal throat infection, the streptococcal organism gains access to the mucous membranes of the throat.
Which of the following statements 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 stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Stem cells comprise only a small portion of all types of bone marrow cells.Research conducted with mouse models has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in human subjects with certain types of immune dysfunction such as severe combined immunodeficiency (SCID). Clinical trails are underway in patients with a variety of disorders with an autoimmune component including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis.
The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?
Corticosteroids. -The nurse obtains a history of immunizations, recent and past infectious diseases, and recent exposure to infectious diseases. He or she reviews the client's drug history because certain drugs, such as corticosteroids, suppress the inflammatory and immune responses. Advil is a nonsteroidal anti-inflammatory medication and does not suppress the inflammatory and immune responses. An ACE-I prevents the conversion of angiotensin I to angiotensin II and does not suppress the inflammatory or immune response. Diuretics also do not suppress the immune response but help reduce excess fluid from the kidneys.
A client will be taking the tumor necrosis factor inhibitor, infliximab (Remicade), for the treatment of rheumatoid arthritis. Prior to beginning this therapeutic regimen, what screening should the client have?
Screening for tuberculosis. -Before prescribing a TNF inhibitor, clients should be screened for tuberculosis because there is a risk for activating latent tuberculosis. It is not necessary to screen for peptic ulcer disease, syphilis, or rubella prior to beginning TNF inhibitor therapy.
