IMMUNITY MASTERY LEVEL 4

A nurse is instructing a patient who was recently diagnosed with multiple sclerosis about dantrolene (Dantrium). The patient is a 38-year-old-male and the foreman for a construction company. In order to minimize one important adverse effect of the drug, the nurse will give the patient which instruction? Eat a high-protein diet. Decrease the dosage if any adverse effect is experienced. Wear appropriate clothing and sunscreen whenever he is in direct sunlight. Have a complete blood cell count done weekly.

Wear appropriate clothing and sunscreen whenever he is in direct sunlight. The nurse will need to caution the patient about the adverse effect of photosensitivity, especially considering his work. He should be advised to wear protective clothing and sunglasses and to use sunscreen whenever he is outside on the job site. A complete blood cell count should be done before therapy begins but would not be needed again unless indicated. A nurse must check with the prescriber before advising a patient to decrease a drug dosage. A diet high in protein is not necessary with this drug.

A pregnant woman reports she is interested in breastfeeding to promote improved health for her child. Which statement by the nurse is most appropriate? "Breastfeeding will improve your child's health." "Breastfeeding provides what is called active immunity." "Passive immunity can be transmitted to your child providing him with some temporary immunity against illness." "Lifelong immunity is provided against some bacterial illnesses from breasting."

"Passive immunity can be transmitted to your child providing him with some temporary immunity against illness."

A 10-year-old boy has been brought to the emergency department (ED) by ambulance in apparent anaphylaxis after accidentally eating a snack bar that contained peanuts. The ED nurse should be aware that this patient's signs and symptoms are attributable to: Dissolution of the basement membranes of epithelium Rapid activation of the clotting cascade A massive release of histamine Activation of the sympathetic nervous system (SNS)

A massive release of histamine Anaphylaxis occurs when the body's immune system produces specific IgE antibodies toward a substance that is normally nontoxic (eg, food such as a peanut). If the substance is ingested more than once, the body releases excess amounts of the protein histamine, resulting in anaphylaxis. The pathophysiology of anaphylaxis is not a consequence of the dissolution of the basement membrane, SNS activation, or inappropriate clotting.

A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder? AIDS DAF CVID SCID

AIDS, the most common secondary disorder, is perhaps the best-known secondary immunodeficiency disorder. It results from infection with the human immunodeficiency virus (HIV). DAF refers to lysis of erythrocytes due to lack of decay-accelerating factor (DAF) on erythrocytes. CVID is a disorder that encompasses various defects ranging from IgA deficiency (in which only the plasma cells that produce IgA are absent) to severe panhypoglobulinemia (in which there is a general lack of immunoglobulins in the blood). Severe combined immunodeficiency disease (SCID) is a disorder in which both B and T cells are missing.

A nurse is working in a pediatric clinic. After giving a hepatitis B immunization to an infant, the parent asks what kind of protection this provides for the child. What is the nurse's best response? Active acquired immunity, which lasts many years or a lifetime Active acquired immunity, which is temporary Passive acquired immunity, which lasts many years or a lifetime Passive acquired immunity, which is temporary

Active acquired immunity, which lasts many years or a lifetime

The nurse is teaching a class to pregnant adolescents and young adults. What does the nurse explain is the most important reason for breastfeeding instead of bottle feeding? breastfeeding is cheaper than bottle feeding breastfeeding provides protection against infections breastfeeding promotes closeness with the neonate breastfeeding is easier to do during the night

Breastfeeding provides protection against infections

More than 50% of individuals with this disease develop pernicious anemia: Bruton disease Common variable immunodeficiency (CVID) DiGeorge syndrome Nezelaf syndrome

Common variable immunodeficiency (CVID) More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions. CH 36 Hinkle Page 1024

A patient who suffered severe partial thickness burns to the face and trunk is at risk for depletion of essential proteins and immunoglobulins. The stressors associated with this patient's major injury have caused what immune process to occur? Cortisol is released from the adrenal cortex, which contributes to immunosuppression. Circulating lymphocytes will cause lymph node enlargement and altered lymph drainage. T lymphocytes are stimulated and produce antibodies. With the help of macrophages, B lymphocytes recognize the antigen of a foreign invader.

Cortisol is released from the adrenal cortex, which contributes to immunosuppression. Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. The physiologic and psychological stressors associated with surgery or injury stimulate cortisol release from the adrenal cortex; increased serum cortisol also contributes to suppression of normal immune responses (Jeckel, Lopes, Berleze, et al., 2010).

The nurse is caring for a client who has a low level of T lymphocytes. The nurse plans care for a client with: Decreased immune response Decreased hematocrit Anemia Infection

Decreased immune response

A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication? Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) Decreased muscle spasms in the lower extremities Increased muscle strength in the upper extremities Promotion of urinary continence

Decreased muscle spasms in the lower extremities Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. It is not used to promote continence or to increase strength. Avonex and Betaseron reduce the appearance of new lesions on the MRI.

At which point is the treatment (RhoGAM) for the hemolytic disease of the newborn FINISHED? During the prenatal period Immediately before delivery During the postpartum period It is no longer needed after the first pregnancy.

During the postpartum period The treatment for Rh incompatibility is RhoGAM; it is given to prevent complications during the second pregnancy and is administered in the postpartum period. This prevents antibodies from entering fetal circulation and hemolyzing or destroying the fetus's RBC.

A nurse is giving a talk to high school students about preventing the spread of human immunodeficiency virus (HIV). What does the nurse identify as ways in which HIV is spread? Select all that apply. Exposure to blood and body fluids through sexual contact Sharing contaminated needles Sharing the same bathroom Transfusion of contaminated blood Perinatally from mother to fetus Through breastfeeding

Exposure to blood and body fluids through sexual contact Sharing contaminated needles Transfusion of contaminated blood Perinatally from mother to fetus Through breastfeeding

A client's chemotherapeutic regimen includes procarbazine. What is the client's most likely diagnosis? Hodgkin lymphoma Neuroblastoma Astrocytoma Pancreatic cancer

Hodgkin lymphoma Procarbazine (Matulane) is used in combination therapy for treatment of stages III and IV of Hodgkin disease.

Which factor contributes to UTI in older adults? Low incidence of chronic illness Immunocompromise Sporadic use of antimicrobial agents Active lifestyle

Immunocompromise Factors that contribute to urinary tract infection in older adults include immunocompromise, high incidence of chronic illness, immobility, frequent use of antimicrobial agents, incomplete emptying of the bladder, and obstructed urine flow.

Which best explains the role of mucus as a barrier for the body's defense? It promotes the removal of invaders. It sweeps away pathogens. It moves the pathogen to an area for removal. It traps the foreign material and thus inactivates it.

It traps the foreign material and thus inactivates it. Mucus is sticky and traps invaders and inactivates them for later destruction and removal by the body. It does not promote their removal. Cilia sweep away captured pathogens and also move them to an area, causing irritation and leading to removal by coughing or sneezing.

What is the main effect of HIV infection? Poor natural killer cell function Poor B-cell function Poor suppressor T-cell function Poor helper T-cell function

Poor helper T-cell function Helper T cells are also known as CD4+ T cells. These CD4+ T cells are necessary for normal immune function and are the main target of HIV.

When assisting the client to interpret a negative HIV test result, what does the nurse tell the client that this result means? The body has not produced antibodies to the AIDS virus. The client has not been infected with HIV. The client is immune to the AIDS virus. Antibodies to the AIDS virus are in the client's blood.

The body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn. A negative test result should be interpreted as demonstrating that, if infected, the body has not produced antibodies (which takes from 3 weeks to 6 months or longer). Therefore, subsequent testing of an at-risk client must be encouraged. The test result does not mean that the client is immune to the virus, nor does it mean that the client is not infected. It just means that the body may not have produced antibodies yet. When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately? Mouth sores Sneezing Constipation Tickle in the throat

Throat tickle Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction.

What types of cells are the primary targets of the healthy immune system? Select all that apply. infectious cells foreign cells cancerous cells typical cells

infectious cells foreign cells cancerous cells

The nurse is working with a client who has had an allohematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of nadir. graft-versus-host disease. metastasis. acute leukopenia.

GVHD Graft-versus-host disease is a major cause of morbidity and mortality in clients who have had allogeneic transplant. Clinical manifestations of the disease include diffuse rash that progresses to blistering and desquamation, and mucosal inflammation of the eyes and the entire gastrointestinal tract with subsequent diarrhea, abdominal pain, and hepatomegaly.

What is a common opportunistic infection in AIDS clients? Pneumocystis jiroveci pneumonia (PCP) Chancroid Syphilis Myalgia

PCP PCP is a very common opportunistic infection in individuals with AIDS. It is a common bacteria found in households and does not routinely effect someone with a healthy immune system. Chancroid and syphilis are infections that do not occur commonly in the population in general, including those with AIDS. Myalgia is not an infection, but it is muscle pain, a common symptom of an infection.

A client with breast cancer is prescribed immunotherapy as part of her chemotherapy regimen. The nurse would most likely identify which drug? trastuzumab tamoxifen letrozole raloxifene

trastuzumab Trastuzumab is the first monoclonal antibody (immunotherapy) approved for treating breast cancer. Tamoxifen and raloxifene are selective estrogen receptor modulators. Letrozole is an aromatase inhibitor used to treat advanced breast cancer.

The nurse has just finished administering the DTaP vaccine to a 2-month-old and is educating the parent about immunization. Which statement is accurate? "Bring her back for the second dose when she is 4 months old." "You need to renew this immunization every 10 years." "The 'T' stands for tuberculosis." "There are no side effects from this vaccine."

"Bring her back for the second dose when she is 4 months old." DTaP is given as a series of five injections—at 2, 4, and 6 months; between 15 and 18 months, and between 4 and 6 years. A TdaP booster is needed by 11 to 12 years. There are common side effects such as fever and redness and swelling at the injection site as well as other less common reactions such as seizures. The "T" in the vaccine stands for tetanus.

A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely? Skin biopsy Patch testing Tzanck smear Wood's light examination

Patch Test Patch testing would be most likely for a patient with a history of allergies to identify substances that may be involved with the patient's allergy. A skin biopsy is doen to rule out a malignancy and establish an exact diagnosis. Tzanck smear is used to examine cells from blistering skin conditions. Wood's light examination is used to differentiate epidermal from dermal lesions and hyperpigmented and hypopigmented lesions.

A client is receiving an IV immune stimulant and develops a cardiac arrhythmia. What is the nurse's priority action? Stop the drug immediately. Notify the prescriber that the client is experiencing an adverse effect. Reposition the client Auscultate the client's apical heart rate for 2 minutes.

Stop the drug immediately!!! If a client is receiving an immune stimulant and develops a cardiac arrhythmia, the drug must be stopped immediately. The prescriber should be notified promptly, but the nurse should first pause the infusion. Further assessment would be performed alter. Repositioning won't do shit.

The treatment prescribed for an autoimmune disorder is primarily dependent upon what? The current manifestations of the disease and the mechanisms that cause the disease process The age and gender of the client The presence of existing chronic disorders and the client's medical history Corticosteroids is always the first line of treatment.

The current manifestations of the disease and the mechanisms that cause the disease process Treatment of autoimmune disorders is dependent upon the magnitude of the presenting manifestations and underlying mechanisms of the disease process. Since in many cases the pathophysiologic mechanisms are not always known, treatment may be purely symptomatic. While corticosteroids are often use, they are not always the first line of treatment. The client's age and medical history can be factors in treatment choices but are not the primary consideration.

An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with the parents. The nurse knows to put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear? gloves gown and gloves gown, gloves, and mask gown, gloves, mask, and eye goggles or eye shield

gown, gloves, mask, and eye goggles or eye shield The transmission of SARS isn't fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any healthcare worker providing care for a person with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.

HIV is considered to be a retrovirus because: it carries its genetic information in ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). it converts to a primitive form of virus when duplicated. it carries a genetic marker for a previously discovered virus that was a source of an epidemic in an earlier time period. it reproduces at a rapid rate.

it carries its genetic information in ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). Like other retroviruses, HIV carries its genetic information in ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). In the process of taking over the CD4+ T cell, the virus attaches to receptors on the CD4+ cell, fuses to and enters the cell, incorporates its RNA into the cell's DNA, and then uses the CD4+ cell's DNA to reproduce large amounts of HIV, which are released into the blood. Porth pg 363

A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity? swimming in rivers or lakes hiking in a forested area going horseback riding playing recreational softball

swimming in rivers or lakes When a client with HIV has moved into the AIDS phase of the infection, the client has a very low CD4 count (<200) and is at high risk for opportunistic infections. One such infection is cryptosporidia, which is caused by protozoan parasites that are often found in water. Swimming in a river or lake greatly increases the risk of this exposure. While the client should take protection to avoid pathogens or injury during the other activities listed, none are known to carry a specific risk for the client that the nurse would need to emphasize compared to the risk of cryptosporidia infection from swimming in lakes or rivers.

The nurse has just admitted a 17-year-old diagnosed with bacterial meningitis. The parents of the adolescent tell the nurse, "We just don't understand how this could have happened. Our child has always been healthy and also just received a booster vaccine last year?" How should the nurse respond? "I understand your frustration. Unfortunately immunizations are not 100% effective in preventing the infection." "Are you sure your child received a vaccine for meningitis? Maybe it was a flu vaccine." "Your child was likely exposed to a strain of bacteria not covered with the meningitis vaccine received." "Maybe your child's immune system isn't strong enough to fight off the infection, even with having received the vaccine."

"I understand your frustration. Unfortunately immunizations are not 100% effective in preventing the infection." Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Questioning them about being sure would not be the best response unless there was reason to believe their information was not accurate. There is nothing to lead the nurse to believe that a different strain of bacteria caused the infection, or that the the child's immune system is compromised.

The pediatric nurse is teaching a group of parents about the safe and effective management of fevers in children. What teaching point should the nurse include? "There are certainly dangers with a high fever, but a slightly increased body temperature can actually improve your child's immune response." "The main reason that we treat fevers is because a high body temperature generally makes an infection worse." "It's no longer recommended that children be treated for fevers, because doing so reduces the effectiveness of their immune system." "Bacteria and viruses tend to thrive in a high-temperature environment, overwhelming the immune system. This is why we recommend prompt treatment of fevers."

"There are certainly dangers with a high fever, but a slightly increased body temperature can actually improve your child's immune response." A higher body temperature catalyzes many of the processes involved in the immune response. It would be useful for parents to know this, but it does not mean that fevers are never (or should never be) treated. Extreme childhood fevers pose risks, but not every fever needs to be treated aggressively.

A client who has been exposed to the human immunodeficiency virus (HIV) tests negative. Which explanation by the nurse would be most appropriate? "Congratulations, a negative result means that you're not infected with the virus." "You're one of the lucky ones who are immune to the virus." "You might still go on to develop AIDS even with negative results." "Your body may not have developed antibodies yet, so we need to follow up."

"Your body may not have developed antibodies yet, so we need to follow up." A negative test result means that antibodies to HIV are not in the blood at this time. The person may not be infected or the person's body may not yet have produced antibodies. (The "window" period is 3 weeks to 6 months). The client needs follow-up testing and must continue to take precautions. The negative test result does not mean that the client is immune to HIV, nor does it mean that the client is not infected. It just means that the body may not have produced antibodies

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder? To decrease the body's risk of infection Because an autoimmune disease is a neoplastic disease So the client has strong drug therapy For their immunosuppressant effects

For their immunosuppressant effects Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just so the client has strong drug therapy.

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? Use pressure-relieving devices when the client is in bed or in a wheelchair. Change body position every 2 hours. Help the client perform range-of-motion (ROM) exercises every 8 hours. Use a footboard and trochanter rolls.

Help the client perform range-of-motion (ROM) exercises every 8 hours. Helping the client perform ROM exercises every 8 hours helps in promoting joint flexibility and muscle tone in a client with muscle weakness. Measures such as using pressure-relieving devices or changing the body positions every 2 hours prevents skin breakdown. The nurse should use a footboard and trochanter rolls to promote a neutral body position that will keep the body in good alignment.

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 Assess joint mobility using passive range of motion. Review the urinalysis report for hematuria Assess for hepatosplenomegaly by measuring abdominal girth

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. Joint movement, a urinalysis results positive for hematuria , and measuring abdominal girth are not used to assess for issues with the neurosensory system in relation to immune dysfunction.

The nurse is reviewing the medical history of a 4-year-old child. What would the nurse identify as potentially indicative of a primary immunodeficiency? Select all that apply. Acute otitis media, one episode every 3 to 4 weeks over the past year. Recurrent deep abscess of the thigh Oral thrush, persistent over the past 6 to 7 months Infected laceration requiring IV antibiotic 2 months ago; healed Pneumonia last spring; resolved with antibiotics

Acute otitis media, one episode every 3 to 4 weeks over the past year. Recurrent deep abscess of the thigh Oral thrush, persistent over the past 6 to 7 months Warning signs associated with primary immunodeficiency include four or more new episodes of acute otitis media in 1 year, recurrent deep skin or organ abscesses, persistent oral thrush or skin candidiasis after 1 year of age. A history of infections requiring IV antibiotics to heal and two or more episodes of pneumonia in 1 year are also warning signs.

A nurse observing a client receiving treatment with pyridostigmine for myasthenia gravis notices the client clenching the jaw, salivating excessively, and experiencing muscle weakness, rigidity, and spasm. The nurse interprets these as indicating which of the following? Cholinergic crisis Acetylcholinesterase crisis Hypertensive emergency Status epilepticus

Cholinergic Crisis. Symptoms of cholinergic crisis include severe abdominal cramping, diarrhea, excessive salivation, muscle weakness, rigidity and spasm, and clenching of the jaw. In acetylcholinesterase crisis a pronounced muscular weakness and respiratory paralysis caused by excessive acetylcholine, often a result of overmedication with anticholinesterase drugs. Hypertensive emergency includes retinal hemorrhage, increased intracranial pressure resulting in headache and/or vomiting, and kidney organ failure. Status epilepticus is a medical emergency and can be of different types and caused by brain trauma, infection, or stroke.

A nurse is monitoring the client's progression of human immunodeficiency virus (HIV). What debilitating gastrointestinal condition found in up to 90% of all AIDS clients should the nurse be aware of? Anorexia Chronic diarrhea Nausea and vomiting Oral candida

Chronic diarrhea :( Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of acquired immune deficiency syndrome (AIDS) can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.

Which of the following is the most frequent route of exposure to a latex allergy? Cutaneous Inhalation Mucosal Parenteral

Cutaneous

A client is diagnosed with human immunodeficiency virus (HIV). What information does the nurse provide to best protect the client from advancing to the acquired autoimmodeficiency syndrome (AIDS) phase of this infection? Engage in safer-sex practices at all times. Strictly adhere to antiviral medication therapy. Practice meticulous infection control. Maintain a generally healthy lifestyle.

Strictly adhere to antiviral medication therapy. Antiretroviral therapy (ART) can control HIV and prevent the progression to AIDS. Missing doses of this therapy greatly increases the risk for increased viral activity. Making healthy lifestyle choices is good general advice but does not control viral activity as ART will. The client is not at high risk for contracting opportunistic infections simply by being HIV positive; the degree of risk depends on current cell counts. Once in the AIDS stage of infection, the client is at high risk for infection and needs to take protective measures. Safe sexual practices protect others from the virus.