Pharm CH 15
The nurse is assessing a new client admitted to a nursing home. The client asks the nurse to explain interleukins. The nurse would include which information? "Interleukins directly affect acid-base balance." "Interleukins help the immune system with inflammation." "Interleukins directly affect infection." "Interleukins directly affect anemia."
"Interleukins help the immune system with inflammation." Explanation: Interleukins help the immune system with inflammation. Interleukins do not directly affect acid-base balance, infection, or anemia.
Once a person has been exposed to a particular antigen and a repeat exposure occurs, what stimulates a quicker immune response? Immunity Macrophages Memory T cells Antibodies
Memory T cells Explanation: The memory T and B lymphocytes that are generated remain in the body for a longer time and can respond more rapidly on repeat exposures to an antigen related to their acquired memory.
A client's immune response include phagocytosis of the bacteria that have infected the client. What cells are capable of performing this role in the immune response? Monocytes Basophils Eosinophils Immunoglobulins
Monocytes Explanation: Macrophages, or monocytes, are mature leukocytes capable of phagocytizing an antigen. Basophils are myelocytic leukocytes incapable of phagocytosis; some of them are fixed and do not circulate. Eosinophils are circulating myelocytic leukocytes whose function is unknown. Immunoglobulins are the released form of antibodies.
Once the inflammatory response is under way, which cells engulf and digest the injured cells or the invader? Basophils Neutrophils Eosinophils Monocytes
Neutrophils Explanation: Once the inflammatory response is under way and neutrophils become active, engulfing and digesting injured cells or the invader, they release a chemical that is a natural pyrogen, or fever-causing substance. Basophils are myelocytic leukocytes that are not capable of phagocytosis. Eosinophils are circulating myelocytic leukocytes whose exact function is not understood. Monocytes are mature leukocytes that are capable of phagocytizing an antigen.
A nurse assesses a client and notes an area that is reddened and warm. The nurse understands that these findings are related to: activation of nerve fibers. vasodilation. fluid leakage into tissues. release of pyrogen.
vasodilation. Explanation: Warmth or heat and redness are due to vasodilation. Activation of the nerve fibers would be noted as pain. Fluid leakage into tissues would be assessed as swelling. Pyrogen release would result in a fever.
When explaining the risks of pretransplant immunosuppression, the nurse demonstrates understanding of the process when making which statement? "Serious complications can occur if you are not monitored carefully while you are immunosuppressed." "Once the transplant is completed, complications associated with immunosuppression are no longer a concern." "Excessive immunosuppression can be corrected fairly easily with other medications." "Inadequate immunosuppression increases your risk of developing an infection."
"Serious complications can occur if you are not monitored carefully while you are immunosuppressed." Explanation: For an organ transplant to be successful, the client's immune system must be artificially suppressed after transplant. If immunosuppression is excessive, the client develops serious infections and other adverse effects, such as cancer, because the drug's actions that slow the proliferation of activated lymphocytes also affect any rapidly dividing nonimmune cells. Inadequate immunosuppression increases the risk of organ rejection.
A client who waiting for an organ transplant asks the nurse why the donor organ must be matched. Which response by the nurse would be most appropriate? "Matching helps ensure that the proper organ is prepared." "Matching prevents you from having a reaction." "The closer the match, the less risk there is of rejection." "Matching is required by law before any transplant."
"The closer the match, the less risk there is of rejection." Explanation: All transplants, except autotransplantation, produce an immune response. Therefore, matching a donor's HLA markers as closely as possible to those of the recipient for histocompatibility is essential. The more closely the foreign cells can be matched, the less aggressive the immune reaction will be to the donated tissue.
Which client would be most likely to benefit from the administration of interferon therapy? A client with leukemia A client with tuberculosis A premature neonate A client with asthma and seasonal allergies
A client with leukemia Explanation: Interferons prevent viral replication and suppress some malignant cell reproduction. Consequently, they are used in the treatment of some cancers but not in bacterial infections, asthma or hypersensitivities. A premature neonate is vulnerable to infection but interferons do not broadly confer protection against infections.
While the nurse is providing education prior to an organ transplant, the client asks for an explanation of acute versus chronic rejection reactions. After completing education, what client statement would indicate that additional teaching is necessary? Acute reactions may occur from 10 days to a few months after transplantation. Acute reactions can lead to arterial narrowing or obliteration of blood flow to the organ. Characteristics of chronic reactions include fibrosis of blood vessels and progressive failure of the transplanted organ. Acute reactions may occur up to a few years after transplantation and years of normal function.
Acute reactions may occur up to a few years after transplantation and years of normal function. Explanation: Rejection reactions are acute or chronic. Acute reactions may occur from 10 days to a few months after transplantation. Characteristics include signs of organ failure and vasculitis lesions that often lead to arterial narrowing or obliteration. Treatment with immunosuppressant drugs is usually effective in ensuring short-term survival of the transplant but does not prevent chronic rejection. Chronic reactions occur after months or years of normal function, are caused by both cellular and humoral immunity, and do not respond to increased immunosuppressive drug therapy. Characteristics include fibrosis of blood vessels and progressive failure of the transplanted organ.
The nurse is explaining to a client how an antigen previously encountered elicits a much faster immune response because the body's immune cells "remember" previous encounters with the antigen. The nurse is describing the function of what cells? T cells lymphocytes monocytes B cells
B cells Explanation: After being activated, the B cells form memory cells that will produce antibodies for immediate release in the future if the antigen is encountered again. Although lymphocytes, monocytes, and T cells will then join in the battle to destroy the antigen, they do not produce memory cells as the B cells do.
The nurse is performing an assessment of a client in order to determine the functional status of the client's humoral immunity. What component of the client's immune function should the nurse prioritize? B cells Suppressor T cells Natural killer cells Lymphokine activated killer cells
B cells Explanation: B cells provide humoral immunity. Suppressor T cells are involved with cell-mediated immunity. Natural killer cells are another type of lymphocyte that is not involved in either type of immunity. Lymphokine-activated killer cells are another type of lymphocyte that is not involved in either type of immunity.
A client is currently fighting an infection. What action by the client's immune system involves humoral immunity? B cells react with antigens Helper T cells stimulate lymphocytes Cytotoxic T cells destroy foreign cells Hageman factor is activated
B cells react with antigens Explanation: Humoral immunity involves the recognition of antigens by B cells and the subsequent production of antibodies. T cells participate mainly in cell-mediated immunity and Hageman factor initiates inflammation.
The nurse is caring for a client with leukemia and is describing the effects of the disease and its treatment on myelocytes. What cell should the nurse describe? Basophils T cells B cells Natural killer cells
Basophils Explanation: Basophils are a type of myelocyte. T cells, B cells, and natural killer cells are lymphocytes.
A client with previously good health has become severely ill with a viral infection. Diagnostic testing suggests that the client has had an inadequate immune response. What phenomenon could best account for this inadequate immune response? Body cells that are infected by the virus are being ignored by the immune system The viral wall possesses the human leukocyte antigen The virus is replicated with no involvement from body cells The virus is able to stimulate release of tumor necrosis factor (TNF)
Body cells that are infected by the virus are being ignored by the immune system Explanation: Some body cells that are infected with viruses are minimally changed and are not recognized as a threat by the immune system. Viruses cannot replicate without host cells and viruses cannot possess HLA. Viruses do not stimulate the release of tumor necrosis factor.
The nurse is caring for a client who has immunodeficiency. What would the nurse teaching the client about lymphoid tissues describe the structure and function of? (Select all that apply.) Adrenal medulla Bone marrow Thymus Spleen Thyroid Islets of Langerhans
Bone marrow Thymus Spleen Explanation: Lymphoid tissues include the bone marrow, lymph glands, spleen and thymus. The adrenal medulla and thyroid are not lymphoid tissues. Islets of Langerhans synthesize insulin and glucagon in the pancreas.
Which of the T cells is responsible for destroying pathogens by punching holes in their cell membrane and by secreting cytokines/lymphokines? Regulatory T cells Memory T cells Helper T cells Cytotoxic T cells
Cytotoxic T cells Explanation: Cytotoxic T cells destroy the pathogens, while the helper T cells assist in the process and the memory T cells recall the pathogen for future antigen encounters.
Burn victims have a high potential for infection due to the destruction of several defense mechanisms, external and internal. Why would this be the case? Disruption of intact skin Alterations in nonpathogenic microbial population Increased secretions containing lysozyme Edematous mucus membranes
Disruption of intact skin Explanation: The body's primary external defense mechanism is intact skin, which prevents entry of foreign substances and produces secretions that inhibit microbial growth.
The nurse is describing the function of the complement system in the immune response. What process should the nurse explain? Enhancing inflammation and the immune response Initiating the immune response Creating Ag-Ab complexes that result in antigen destruction Suppressing the immune response when it is no longer needed
Enhancing inflammation and the immune response Explanation: Activation of complement facilitates aggressive inflammatory and immune responses. Complement responds to (but does not create) Ag-Ab complexes. Complement proteins do not perform a suppression role in the immune response.
nurse is required to educate nursing students about the mechanisms that antibodies use to destroy antigens. How do antibodies destroy antigens? (Select all that apply.) Destroy toxins. Facilitate phagocytosis. Imprison invader cells. Complement fixation.
Facilitate phagocytosis. Imprison invader cells. Complement fixation. Explanation: Antibodies use several mechanisms to destroy antigens: neutralizing toxins, facilitating phagocytosis, imprisoning invader cells (granuloma), and complementing fixation.
The nurse is assessing a client who has a venous ulcer on the lower leg. The wound bed and the periwound skin are inflamed. What evidence of vasodilation will the nurse assess? Heat and redness Pain and production of exudate Increased oral temperature Tenderness and emergence of granulation tissue
Heat and redness Explanation: Vasodilation during inflammation causes rubor (redness) and calor (heat). Vasodilation does not directly cause pain. The production of exudate is an end result of the immune response but it is not a direct result of vasodilation. Granulation tissue is part of healing but is not a consequence of vasodilation.
A nurse is addressing a group of nursing students about gamma globulins. What is the best response to the nursing students about the function of IgA? Stimulates complement activity Functions as an antigen receptor Protects the fetus before birth against antitoxins, viruses, and bacteria Helpful in defense against invasion of microbes via nose, eyes, lungs, and intestines
Helpful in defense against invasion of microbes via nose, eyes, lungs, and intestines Explanation: IgA helps in defense against invasion of microbes via nose, eyes, lungs, and intestines. IgM stimulates complement activity. IgD functions as an antigen receptor. IgG protects the fetus before birth against antitoxins, viruses and bacteria.
A deficiency in what area would result in an inhibition of the inflammatory response? Histamine Helper T cells B cells Vitamin K
Histamine Explanation: Histamine is a key mediator in the inflammatory system, unlike helper T cells, B cells, or vitamin K.
A group of students are reviewing class material about lymphoid tissue. The students demonstrate a need for additional teaching when they identify this as lymphoid tissue? Bone marrow Thymus gland Spleen Histamine
Histamine Explanation: Histamine is a substance released when a cell membrane is injured and is not considered lymphoid tissue. Bone marrow, the thymus gland, and the spleen are lymphoid tissues.
A client has sought care because of seasonal allergies that are having a negative effect on the client's quality of life. The nurse should recognize the role of what immunoglobulin in this client's health problem? IgE IgG IgM IgA
IgE Explanation: IgE seems to be related to allergic responses and activation of mast cells. IgG contains antibodies made by memory cells that circulate and enter the tissue. IgM is the first immunoglobulin released on first exposure to an antigen. IgA is secreted by plasma cells in the GI and respiratory tracts and in epithelial cells.
In an allergic reaction, the immunoglobulin that binds to mast cells that release histamine is the: IgE. IgA. IgG. IdD.
IgE. Explanation: IgE immunoglobulin response in allergic response and parasitic infections, while the IgA is the primary defense against local infections in mucosal tissues. IgG protects against bacteria, toxins and viruses, and activates the complement system. The IgD acts as an antigen receptor for initiating the B cells.
Which immunoglobulin is released first when a client encounters an antigen? Immunoglobulin M Immunoglobulin G Immunoglobulin A Immunoglobulin E
Immunoglobulin M Explanation: Immunoglobulin M is the first immunoglobulin released and contains antibodies produced at the first exposure to the antigen. Immunoglobulin G contains antibodies made by the memory cells. Immunoglobulin A is secreted by plasma cells in the gastrointestinal and respiratory tracts and in epithelial cells. Immunoglobulin E appears to be involved with allergic responses and activation of mast cells.
The nurse is reviewing the most recent laboratory findings of a hospital client. The client's neutrophil count is 950/µL (0.95 ×109/L), which is significantly below reference ranges. What is the nurse's best action? Implement isolation precautions as per protocol. Monitor the client closely for signs and symptoms of inflammation. Monitor the client's oral temperature hourly. Relocate the client to a sterile environment.
Implement isolation precautions as per protocol. Explanation: A client with neutropenia is susceptible to infection and should be protected accordingly. Many immunocompromised clients are unable to produce a fever so this assessment is not necessarily a reliable indicator of infection. Low neutrophils do not create a risk for inflammation. A truly sterile inpatient setting is an impossibility since it would require total eradication of all microorganism
A client is lying on the back for more than 3 hours. The client develops a reddened area on the coccyx. What response is noted with the development of the reddened area? Decreased pH Increased protein catabolism Inhibition of cell growth Inflammation
Inflammation Explanation: The cellular response to injury involves inflammation, a generalized reaction to any tissue damage, which attempts to remove the damaging agent and repair the damaged tissue. The cellular response related to a decubitus ulcer does not involve a decrease in pH, increased protein catabolism, or the direct inhibition of cell growth.
Which substance is responsible for stimulating T and B cells to initiate an immune response? Thymosin Tumor necrosis factor Interleukin-1 Interferons
Interleukin-1 Explanation: Interleukin-1 stimulates T and B cells to initiate an immune response. Thymosin is a thymus hormone that is important in the maturation of T cells and cell-mediated immunity. Tumor necrosis factor is a chemical released by macrophages that inhibits tumor growth. Interferons are chemicals secreted by cells that have been invaded by viruses to prevent viral replication and also suppress malignant cell replication and tumor growth.
What best describes the role of the major histocompatibility complex as a barrier defense? It allows the body to distinguish cells as foreign or belonging to the person. It physically prevents pathogens from entering the internal tissues of the body. It protects areas that are exposed to the external environment. It destroys many potential pathogens that are ingested or swallowed.
It allows the body to distinguish cells as foreign or belonging to the person. Explanation: Major histocompatibility complex allows the body to be able to distinguish between self-cells and foreign cells. The skin physically prevents pathogens from entering the body. The mucous membranes protect exposed areas that are not covered by skin. Gastric acid destroys would-be pathogens that are ingested or swallowed.
A client is exposed to a viral infection. What role will interferon most likely play during this exposure? It will stimulate B lymphocyte activity. It will interfere with stem cell multiplication. It will stimulate growth of lymphoid cells. It will interfere with virus replication.
It will interfere with virus replication. Explanation: Interferons interfere with the ability of viruses in infected cells to replicate and spread to uninfected cells. Interferons will not stimulate B lymphocyte activity, stem cell multiplication, or growth of lymphoid cells.
A client has developed a wound infection and leukocytes are leaving the bloodstream to perform phagocytosis on pathogens. What white cells are most likely performing this function? Neutrophils Basophils Eosinophils Monocytes
Neutrophils Explanation: When an injury or invasion occurs, neutrophils are rapidly produced and move to the site of insult to attack the foreign substance. Basophils are not capable of phagocytosis but contain chemicals that can initiate or maintain an immune response and may be fixed or circulate in the blood. Eosinophils are not well understood but are often found at the site of an allergic reaction. Monocytes are capable of phagocytosis and show up in greater numbers after the neutrophils to remove debris.
The nurse assists and educates clients on the difference between nonspecific and specific immunity. The body possesses several defense systems. Which nonspecific defense mechanism provides a physical barrier and secretes enzymes that kill or reduce the virulence of bacteria? Skin Mechanical reactions Chemical barriers Tears
Skin Explanation: The skin provides a physical barrier and secretes enzymes that kill or reduce the virulence of bacteria. Mechanical reactions, such as coughing or sneezing, help remove pathogenic material. Chemical barriers, such as the normal flora (microorganisms) of the GI system, neutralize or kill microorganisms. Tears dilute and wash away irritating substances and microbes.
A client became ill with an influenza virus several days ago. Today, the client describes being free of symptoms. What component of the immune system will be predominant today? Suppressor T cells Complement proteins Interleukins Cytokines
Suppressor T cells Explanation: Suppressor T cells play an important role in limiting the immune response and preventing it from become too aggressive or too prolonged. Complement proteins, interleukins, and cytokines would be more significant during the active response to the pathogens.
What does the clinical presentation of an inflammatory reaction include? (Select all that apply.) Swelling Pain Heat Drainage Redness
Swelling Pain Heat Redness
Which cells are responsible for cell-mediated immunity? T cells B cells Neutrophils Immunoglobulins
T cells Explanation: T cells provide cell-mediated immunity. B cells provide humoral immunity, which involves antibody or immunoglobulin production. Neutrophils are not associated with either cell-mediated or humoral immunity.
What is the primary difference between acute and chronic inflammation? Active inflammation is weaker in its response than the chronic form. The chronic form can stimulate cellular damage. Chronic inflammation is incapable of producing fibrotic tissue. The active form is much more painful than the chronic form.
The chronic form can stimulate cellular damage. Explanation: Unlike acute inflammation, chronic inflammation may last for weeks, months, or even years. It can be harmful by stimulating more cellular damage and even causing healthy tissue to become scarred and/or fibrotic. Acute inflammation is a response to cellular injury that can last from minutes to a few days. It is protective and part of the process of tissue healing. The response of active inflammation is not necessarily weaker than that of the chronic form nor is it more painful.
A client is experiencing an immune response and the only immunoglobulin that is currently in circulation is IgM. How should the nurse best interpret this fact? The client has very recently been exposed to the antigen The client has neutropenia The client has a very low CD4 count The client is experiencing an autoimmune disease
The client has very recently been exposed to the antigen Explanation: IgM is the first immunoglobulin released, so there could theoretically be a lag between IgM release and the release of other immunoglobulins. This phenomenon would be unrelated to low levels of neutrophils, low CD4 cells or an autoimmune process.
A client has been diagnosed with an autoimmune disease that causes numerous distressing symptoms. What pathophysiologic process is causing this client's symptoms? The client's body is producing antibodies against the client's own self-antigens. Viruses have taken over the client's B cells, causing them to attack the client's own cells. Cytotoxic T cells have begun to phagocytize one another, rather than pathogens. B cells are producing antibodies that promote cell malignancy.
The client's body is producing antibodies against the client's own self-antigens. Explanation: Autoimmune disease occurs when the body responds to specific self-antigens to produce antibodies or cell-mediated immune responses against its own cells. This does not occur, however, because viruses have "taken over" healthy cells or because cytotoxic T cells have turned on one another. Malignancy is not normally involved.
A client has developed Kaposi's sarcoma. What defense mechanism is the most affected by this homeostatic change initially? The mucous membrane is affected. The respiratory tract is affected. The skin is affected. The gastrointestinal tract is affected.
The skin is affected. Explanation: With Kaposi's sarcoma, skin lesions may resolve or stabilize over several weeks. None of the other mechanisms are initially affected.
A client is receiving immunizations before traveling to a storm-stricken region of the tropics where cholera, typhoid, and malaria are in epidemic. While specific immunizations to combat specific diseases would be administered, why would an injection of IgA also be administered? To increase local antibody response To increase humoral response To increase cellular response To increase cellular stimulation
To increase local antibody response Explanation: Antibodies (mostly immunoglobulin A [IgA]) secreted at these sites act locally rather than systemically, combating foreign substances (especially pathogens) that are inhaled, swallowed, or otherwise come in contact with external body surfaces.
When a virus invades the body, it must enter a host cell to obtain nutrients necessary to replicate. True False
True Explanation: Viruses are parasites that can survive only by invading a host cell that provides the nourishment necessary for viral replication.
Within an infected wound bed, many cell types are involved in protecting the host and eliminating the "foreign invaders" to promote wound healing. How does the identification of body tissues from foreign substances occur? Via the immune system Via the inflammatory system Via the hemodynamic system Via the cellular system
Via the immune system Explanation: The immune system detects and eliminates foreign substances that may cause tissue injury or disease.
The inflammatory response is activated whenever cell injury occurs. An inflammatory response would involve which activities? a. Activation of Hageman factor b. Vasodilation in the area of the injury c. Generalized edema and tumor development d. Changes in capillary permeability to allow proteins to leak out of the capillaries e. Activation of complement proteins f. Production of interferon
a. Activation of Hageman factor b. Vasodilation in the area of the injury d. Changes in capillary permeability to allow proteins to leak out of the capillaries
Which of the following statements could be used to describe a neutrophil? a. They possess the property of phagocytosis. b. When activated, they release a pyrogen that causes fever. c. When the body is injured, they are produced rapidly and in large numbers. d. They are not capable of movement outside the circulatory system. e. They are most often seen in response to an allergic reaction. f. They float around in the blood and release chemicals in response to injury.
a. They possess the property of phagocytosis. b. When activated, they release a pyrogen that causes fever. c. When the body is injured, they are produced rapidly and in large numbers.
A client has been exposed to a rhinovirus and the client's immune system has been activated. The client's immune response will include: activation of complement proteins and interleukins. suppression of the pathogen by suppressor (CD8) T cells. antibody formation by T cells synthesis and release of IgA by neutrophils.
activation of complement proteins and interleukins. Explanation: The complement system and interleukins participate in the immune response. Suppressor T cells limit the immune response rather than directly suppressing pathogens. T cells do not produce antibodies and neutrophils do not produce immunoglobulins of any type.
Which of the following is not a cytokine? a. Interleukin-2 b. Antibody c. Tumor necrosis factor d. Interferon
b. Antibody
Treating fevers remains a controversial subject because higher temperatures a. make people feel ill. b. act as catalysts to many of the body's chemical reactions. c. can suppress the body's normal metabolism. d. alter the body's hormone levels, particularly that of progesterone.
b. act as catalysts to many of the body's chemical reactions.
Interleukins are a. chemicals released when a virus enters a cell. b. chemicals secreted by activated leukocytes. c. part of the kinin system. d. activated by arachidonic acid.
b. chemicals secreted by activated leukocytes.
As part of the nonspecific defense against infection, a. blood flow and vascular permeability to proteins increase throughout the circulatory system. b. particles in the respiratory tract are engulfed by phagocytes. c. B cells are released from the bone marrow. d. neutrophils release lysosomes, heparin, and kininogen into the extracellular fluid.
b. particles in the respiratory tract are engulfed by phagocytes.
B and T cells are similar in that they both a. secrete antibodies. b. play important roles in the immune response. c. are activated in the thymus gland. d. release cytotoxins to destroy cells.
b. play important roles in the immune response.
Some leukotrienes have the ability to attract neutrophils and to stimulate them. This property is known as: phagocytosis. differentiation. homeostasis. chemotaxis.
chemotaxis. Explanation: Chemotaxis is the property of drawing neutrophils into the area.
After describing the function of T cells, the nurse would identify the need for additional teaching if the patient stated that T cells become which type of cells? a. Cytotoxic T cells b. Helper T cells c. Suppressor T cells d. Antibody-secreting T cells
d. Antibody-secreting T cells
A client's most recent laboratory work reveals neutropenia. This client will have a diminished capacity for what process? phagocytosis producing memory cells marking cells for destruction complement production
phagocytosis Explanation: Neutrophils engulf and digest foreign material through the process of phagocytosis. B cells produce memory cells. Cytotoxic T cells mark cells for destruction. Neutrophils do not produce complement.
Antibodies a. are carbohydrates. b. are secreted by activated T cells. c. are not found in circulating gamma globulins. d. are effective only against specific antigens.
d. are effective only against specific antigens.
B cells respond to an initial antigen challenge by a. reducing in size. b. immediately producing antigen-specific antibodies. c. producing a large number of cells that are unlike the original B cell. d. producing new cells that become plasma cells and memory cells.
d. producing new cells that become plasma cells and memory cells.
The defense mechanism involving lymphoid cells, inflammatory cells, and hematopoietic cells stimulates production of antibodies and activated lymphocytes to destroy mutant body cells and pathogens is known as: immune response. phagocytosis. inflammatory response. cellular response.
immune response. Explanation: The final defense mechanism is the immune response, and an effective response involves lymphoid cells, inflammatory cells, and hematopoietic cells.
A client admitted to the ICU with gunshot wounds in the chest and thigh is noted to have extensive edema present. Anticipating a generalized reaction to tissue damage, the nurse concludes that the client's edema is the result of what development? inflammatory process. hypoxia. vasoconstriction. internal pathogenic control.
inflammatory process. Explanation: The cellular response to injury involves inflammation, a generalized reaction to any tissue damage, which attempts to remove the damaging agent and repair the damaged tissue. The hemodynamic aspect of inflammation includes vasodilation, which increases blood supply to the injured area, and increased capillary permeability, which allows fluid to leak into tissue spaces.
The nurse reviews the Nurse's Notes which contains data collected during the assessment of a client with a swollen knee. Based on this information, which condition should the nurse suspect the client is experiencing? allergic response arthritis of the knee undiagnosed fracture inflammatory response
inflammatory response Explanation: Activation of the acute inflammatory response causes specific characteristics. The first is warmth of the area caused by increased blood flow to the tissues. The area becomes edematous because of fluid leaking into the tissues. Redness occurs because of increased blood flow from vasodilation. Pain is caused by the activation of pain fibers in the tissues. A fever occurs as the body attempts to remove injured cells from the area. The client's symptoms do not indicate an allergic response. Arthritis would not cause a fever or redness of the skin. The client would have more pain if a fracture were present.
What assessment data would confirm that a client is demonstrating the presence of effective major defense mechanisms? Select all that apply. an increased platelet cell count intact skin and mucous membranes redness and heat at the site of a cut an elevated temperature an elevated white blood cell count
intact skin and mucous membranes redness and heat at the site of a cut an elevated temperature an elevated white blood cell count Explanation: Although the numbers and virulence of microorganisms help determine whether a person acquires an infection, another major factor is the host's ability to defend itself against the would-be invaders. Major defense mechanisms of the human body are intact skin and mucous membranes, various anti-infective secretions, mechanical movements, phagocytic cells, and the immune and inflammatory processes
A post-surgical client has an oral temperature of 38.2°C (100.8°F) and reports muscle pain and "aching elbows and shoulders." The nurse should recognize the likely role of: interleukins. interferons. tumor necrosis factor. thymosin.
interleukins. Explanation: Interleukins cause fever, arthralgia, myalgia, and slow wave sleep induction. Interferons prevent viral replication and suppress malignant cell replication and tumor growth. Tumor necrosis factor works with other chemicals to make the inflammatory and immune responses more aggressive and efficient. Thymosin is important in the maturation of T cells and cell-mediated immunity.
Which cells participate in this effort to control tissue injury associated with the second stage of the inflammation process? B cells neutrophils monocytes natural killer cells
neutrophils Explanation: The second stage of acute inflammation is also known as the cellular stage. At this time, there is an influx of leukocytes, primarily neutrophils, to the injury site. As the leukocytes invade, there is a slowing of the blood flow and margination, which is the adhesion of the leukocytes to the wall of the blood vessels. B cells, monocytes, and NK cells are not central to this aspect of inflammation
What is the meaning of the term dolor, when used to describe a characteristic of the inflammatory response? pain swelling redness heat
pain Explanation: The clinical presentation of an inflammatory reaction is heat (calor), redness (rubor), swelling (tumor), and pain (dolor).
A client's exposure to an infectious microorganism has stimulated the client's immune response, including activation of effector (cytotoxic) T cells. These cells will help to eliminate pathogens by: releasing cytokines that will destroy the foreign cells. stimulating B cells to become more immunologically active. releasing antibodies from within their cells membrane. initiating the inflammatory response.
releasing cytokines that will destroy the foreign cells. Explanation: Effector (cytotoxic) T cells release cytokines that either destroy the pathogen directly or mark it for destruction by phagocytes. Helper T cells stimulate the function of B cells. Effector T cells do not contain antibodies, which are produced by B cells. Effector T cells do not initiate the inflammatory response.
The first physical line of defense in innate immunity is: plasma proteins. skin and mucous membranes. specialized lymphocytes. neutrophils.
skin and mucous membranes. Explanation: The first physical line of defense in immunity is the skin and mucous membranes, which prevent pathogens from entering if they are intact. The other options are cellular level protection.
A 56-year-old client, discharged from the hospital following a successful kidney transplant, is prescribed antirejection drug therapy. When performing health education with the client and the client's family, which topic should the nurse emphasize? the safe use of any required assistive devices strategies for reducing the client's risk of infection strategies for managing the client's energy and activity levels the role of nutrition in health maintenance and the prevention of rejection
strategies for reducing the client's risk of infection Explanation: With clients who are taking immunosuppressant drugs, a major role of the home care nurse is to assess the environment for potential sources of infection, assist clients and other members of the household to understand the client's susceptibility to infection, and teach ways to decrease risks of infection. This is more important than activity management, mobility, and nutrition, though each of these subjects warrants education.
A client who is a young adult was immunized against pertussis as a child and has now been exposed to the causative bacteria, Bordetella pertussis. The client's exposure to this bacteria will cause: the release of IgG by memory B cells. antibody release from the client's thymus. the inflammatory response to be accelerated. more rapid phagocytosis by neutrophils.
the release of IgG by memory B cells. Explanation: Exposure to a pathogen following immunization causes the memory B cells to release the IgG antibodies that were formed after the client was vaccinated. These antibodies are not necessarily sequestered in the thymus. Vaccination does not directly affect the speed of the inflammatory response or phagocytosi
