NUR415 PrepU Ch.12: Disorders of the Immune Response

The nurse is preparing to administer a unit of blood to a client. The client says that he is not sure he wants to give consent to receive the blood transfusion because he does not want to get HIV/AIDS from the blood. How will the nurse respond?

"All blood is now tested for HIV, so the risk of getting HIV/AIDS from a blood transfusion is extremely low."

When a client who has been newly diagnosed with HIV asks, "What are the chances that I can be cured?," what is the nurse's most therapeutic response?

"Although there is no current treatment that provides a possible cure, there are ones that have successfully managed the infection."

The nurse is teaching a group of college students about reducing the risk of HIV transmission during sexual relations. The nurse makes which appropriate teaching point?

"If a person has a sexually transmitted disease (STD), there is an increased risk for HIV infection."

The nurse is caring for a client who has just learned that he is HIV positive. The client asks the nurse how long he has been able to infect others. Select the best response by the nurse.

"You can infect others before the HIV antibody is detectable in your blood."

A client develops an immunodeficiency disorder after receiving chemotherapy for the treatment of lung cancer. The client asks the nurse if he was born with this deficiency. What is the nurse's best response?

"You have developed a secondary immunodeficiency disorder as a result of your chemotherapy."

A client recently diagnosed with leukocyte adhesion deficiency (LAD) asks, "Why am I always sick with an infection?" Which response by the nurse explains this rare autosomal recessive disorder?

"Your white blood cells are not able to leave the blood vessels and move into the area of infection."

Which statement about HIV/AIDS is true?

Accidental stick with a needle used on an HIV-infected client carries little risk of infection.

An infant is suspected of having a severe primary immunodeficiency disease. Which effect on the infant makes early detection a priority?

Administering live attenuated virus vaccines can be fatal.

A child has experienced a bee-sting while at the park. The health care provider is walking by and notices the child has swelling around the eyes, lips, and face in general. What priority assessment should the nurse make at this time?

Assess and establish an open airway.

A client has been admitted to the hospital for the treatment of HIV infection, which has recently progressed to overt AIDS. Which nursing action should the nurse prioritize when providing care for this client?

Astute infection control and respiratory assessments

Combined immunodeficiency (CID) is distinguished by low, not absent, T-cell function. These diseases are usually associated with other disorders and arise from diverse genetic causes. Which of the following diseases is considered a CID?

Ataxia-telangiectasia

Select the statement that best describes autoimmune disease.

Autoimmune diseases represent a disruption in self-tolerance that results in damage to body tissues by the immune system.

Which type of a hypersensitivity reaction involves failure of the development of self-tolerance?

Autoimmune reaction

A diagnosis of acquired immunodeficiency syndrome (AIDS) is identified when the CD4+ T cell count reaches which level?

Below 200 cells/μL

A client with end-stage renal disease received a kidney transplant with a kidney donated by a family member. The client has been carefully monitored for signs of rejection. The physician informs the client that there has been a gradual rise in the serum creatinine over the last 5 months. What type of rejection does this depict?

Chronic rejection

Which client would be diagnosed with wasting syndrome?

Client with AIDS, fever, diarrhea, and significant involuntary weight loss

In providing education to a sexually active 22-year-old female, which topic would be most beneficial to discuss to decrease her risk for contracting HIV?

Consistent use of latex condoms with sexual activity

The nurse is caring for a client who is HIV positive and is newly diagnosed with Mycobacterium tuberculosis (TB). Which manifestations does the nurse associate with TB? Select all that apply.

Cough Fever Night sweats

The nurse is counseling a group of clients about the importance of early testing for the human immunodeficiency virus (HIV). Which information will the nurse share?

HIV can cause no significant symptoms for an average of 10 years.

Which clinical manifestation would not be exhibited during an anaphylactic reaction?

Hypertension

A client with common variable immunodeficiency (CVID) is admitted to the hospital for treatment. Which type of treatment will the nurse be administering to the client?

IV immunoglobulin

A client is being treated for an anaphylactic reaction after eating shrimp. Which class of antibodies mediates the anaphylaxis?

IgE

In a newborn, which antibody crosses the placenta to provide protection from infection?

IgG

Which is a characteristic finding in AIDS?

Kaposi sarcoma

A client with hereditary angioneurotic edema (HAE) is experiencing an attack. Which priority intervention should the nurse be prepared to administer?

Maintaining a patent airway

What would constitute a normal assessment finding in a neonate?

Minimal or absent levels of IgA and IgM

Typical symptoms seen in the latent period of HIV infection include which of the following?

No signs or symptoms

A client with a diagnosis of aplastic anemia has undergone allogenic bone marrow transplantation. Which signs and symptoms would most clearly suggest the existence of graft-versus-host-disease (GVHD)?

Presence of a pruritic rash that has begun to slough off

A nurse has just learned that her child has a life-threatening complement disorder known as hereditary angioneurotic edema (HAE). Due to deficiency in C1-INH, the nurse needs to be prepared for which possible life-threatening clinical manifestation?

Swelling of the airway

A client with a diagnosis of cirrhosis has experienced an acute rejection of a donor liver. Which cell is most likely responsible for the rejection of the client's transplanted organ?

T cells

The nurse understands that a positive ELISA test reported in a baby born to a woman who is HIV positive indicates:

The baby has antibodies from the mother and it is uncertain whether the baby is infected with HIV.

A nurse is caring for a child diagnosed with DiGeorge syndrome with thymic hypoplasia. Which immune response would the nurse anticipate in this child?

The child with thymic hypoplasia will be at increased risk of infection.

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

What is the most common mode of transmission of HIV?

Vaginal and anal intercourse

A 20-year-old male presents at the clinic complaining of severe fatigue, night sweats, and fever. While taking the client's history, he reports having multiple sexual partners and unprotected sex. HIV/AIDS is suspected. What diagnostic test would be ordered to confirm the diagnosis?

Western blot assay

Which regimen serves as the rationale for HIV/AIDS treatment with antiretroviral therapy?

combination therapy incorporating the five classes of antiretroviral drugs

Manifestations of Kaposi sarcoma include:

lesions of the skin and in the oral cavity, gastrointestinal tract, and lungs.