Physiological Safety Test Bank

A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? A)Arrange for a portable x-ray machine to be used. B)Have the patient wear a mask to the x-ray department. C)Ensure that the radiology department has been disinfected prior to the test. D)Send the patient to the x-ray department, and have the staff in the department wear masks.

A - A patient who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the patients room. This confers more protection than disinfecting the radiology department or using masks.

During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess? A)Acquired immunity B)Natural immunity C)Phagocytic immunity D)Humoral immunity

A - Acquired immunity usually develops as a result of prior exposure to an antigen, often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three means of defense. The first line of defense, the phagocytic immune response, involves the WBCs that have the ability to ingest foreign particles. A second protective response is the humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells that manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present at birth.

A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea? A)Administer antidiarrheal medications on a scheduled basis, as ordered. B)Encourage the patient to eat three balanced meals and a snack at bedtime. C)Increase the patients oral fluid intake. D)Encourage the patient to increase his or her activity level.

A - Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis, provided the patients diarrhea is not caused by an infectious microorganism. Increased oral fluid may exacerbate diarrhea; IV fluid replacement is often indicated. Small, more frequent meals may be beneficial, and it is unrealistic to increase activity while the patient has frequent diarrhea.

An infection control nurse is presenting an inservice reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining? A)Agglutination B)Cellular immune response C)Humoral response D)Phagocytic immune response

A - Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link between two antigens. This takes place within the context of the humoral immune response, but is not synonymous with it. Cellular immune response, the immune systems third line of defense, involves the attack of pathogens by T-cells. The phagocytic immune response, or immune response, is the systems first line of defense, involving white blood cells that have the ability to ingest foreign particles.

Patient teaching regarding infection prevention for the patient with an immunodeficiency includes which of the following guidelines? A)Cook all food thoroughly. B)Refrain from using creams or emollients on skin. C)Maintain contact only with individuals who have recently been vaccinated. D)Take OTC vitamin supplements consistently.

A - All foods must be cooked to avoid food-borne illness. The patient should avoid contact with individuals who have recently been ill or vaccinated. The nurse should apply creams and emollients to any dry, chaffed, or cracked skin. Vitamin supplements may or may not be indicated.

A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient? A)Ineffective Airway Clearance B)Impaired Oral Mucous Membranes C)Imbalanced Nutrition: Less than Body Requirements D)Activity Intolerance

A - Although all these nursing diagnoses are appropriate for a patient with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the patient with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns.

Family members of an immunocompromised patient have asked the nurse why antibiotics are not being given to the patient in order to prevent infection. How should the nurse best respond? A)Using antibiotics to prevent infections can cause the growth of drug-resistant bacteria. B)If an antibiotic is given to prevent a bacterial infection, the patient is at risk of a viral infection. C)Antibiotics can never prevent an infection; they can only cure an infection that is fully developed. D)Antibiotics cannot resolve infections in people who are immunocompromised.

A - Although prophylactic drug treatment effectively prevents some bacterial and fungal infections, it must be used with caution because it has been implicated in the emergence of resistant organisms. Use of antibiotics does not directly increase the risk of viral infections.

The nurse is providing care for a patient who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment? A)Stem cell transplantation B)Serial immunizations C)Immunosuppression D)Genetic engineering

A - Clinical trials using stem cells are under way in patients with a variety of disorders having an autoimmune component, including multiple sclerosis. Immunizations and genetic engineering are not used to treat multiple sclerosis. Immunosuppression would exacerbate symptoms of MS.

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 - Corticosteroids such as prednisone can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts.

A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk? A)Utilize a pressure-reducing mattress. B)Limit the patients physical activity. C)Apply antibiotic ointment to dependent skin surfaces. D)Avoid contact with synthetic fabrics.

A - Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Activity should be promoted, not limited, and contact with synthetic fabrics does not necessary threaten skin integrity. Antibiotic ointments are not normally used unless there is a break in the skin surface.

A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodeficiency disease (SCID). What medication should the nurse administer prior to initiating the infusion? A)Diphenhydramine B)Ibuprofen C)Hydromorphone D)Fentanyl

A - Diphenhydramine and acetaminophen are administered 30 minutes prior to an IVIG infusion.

A home health nurse is caring for a patient who has an immunodeficiency. What is the nurses priority action to help ensure successful outcomes and a favorable prognosis? A)Encourage the patient and family to be active partners in the management of the immunodeficiency. B)Encourage the patient and family to manage the patients activity level and activities of daily living effectively. C)Make sure that the patient and family understand the importance of monitoring fluid balance. D)Make sure that the patient and family know how to adjust dosages of the medications used in treatment.

A - Encouraging the patient and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favorable prognosis. This transcends the patients activity and functional status. Medications should not be adjusted without consultation from the primary care provider. Fluid balance is not normally a central concern.

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV? A)Gay, bisexual, and other men who have sex with men B)Recreational drug users C)Blood transfusion recipients D)Health care providers

A - Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 2% of the population but 61% of the new infections. This exceeds the incidence among drug users, health care workers, and transfusion recipients.

A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication? A)HIV encephalopathy B)B-cell lymphoma C)Kaposis sarcoma D)Wasting syndrome

A - HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations.

An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL, and the nurse recognizes the patients increased risk for Mycobacterium aviumcomplex (MAC disease). The nurse should anticipate the administration of what drug? A)Azithromycin B)Vancomycin C)Levofloxacin D)Fluconazole

A - HIV-infected adults and adolescents should receive chemoprophylaxis against disseminatedMycobacterium avium complex (MAC disease) if they have a CD4+ count less than 50 cells/L. Azithromycin (Zithromax) or clarithromycin (Biaxin) are the preferred prophylactic agents. Vancomycin, levofloxacin, and fluconazole are not prophylactic agents for MAC.

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 - 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.

The nurse is caring for a patient with an immunodeficiency who has experienced sudden malaise. The nurses colleague states, Im pretty sure that its not an infection, because the most recent blood work looks fine. What principle should guide the nurses response to the colleague? A)Immunodeficient patients will usually exhibit subtle and atypical signs of infection. B)Infections in immunodeficient patients have a slower onset but a more severe course. C)Laboratory blood work is often inaccurate in immunodeficient patients. D)Immunodeficient patients do not develop symptoms of infection.

A - Immunodeficient patients often lack the typical objective and subjective signs and symptoms of infection. However, this does not mean that they wholly lack symptoms. Infections do not normally have a slower onset. Blood work may not be a reliable diagnostic tool, but that does not mean that the results are inaccurate.

A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurses choice of educational interventions? A)Many older adults do not see themselves as being at risk for HIV infection. B)Many older adults are not aware of the difference between HIV and AIDS. C)Older adults tend to have more sex partners than younger adults. D)Older adults have the highest incidence of intravenous drug use.

A - It is known that many older adults do not see themselves as being at risk for HIV infection. Knowledge of the relationship between HIV infection and AIDS is not known to affect the incidence of new cases. The statements about sex partners and IV drug use are untrue.

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 - 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 who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention? A)Teach the patient guided imagery. B)Give the patient more control of her antiretroviral regimen. C)Increase the patients activity level. D)Collaborate with the patients physician to obtain an order for hydromorphone.

A - Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue. Increased activity may be of benefit, but for other patients this may exacerbate feelings of anxiety or loss. Granting the patient control has the potential to reduce anxiety, but the patient is not normally given unilateral control of the ART regimen. Hydromorphone is not used to treat anxiety.

A patient with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse caring for the patient should prioritize which of the following? A)Protective isolation B)Fresh-frozen plasma administration C)Chest physiotherapy D)Nutritional supplementation

A - Patients with Wiskott-Aldrich syndrome (WAS) are at a grave risk for infection; infection prevention is a priority aspect of nursing care. Nutritional supplementation may be necessary, but infection prevention is paramount. Chest physiotherapy and FFP administration are not indicated.

The nurse is caring for a patient who has a diagnosis of paroxysmal nocturnal hemoglobinuria. When planning this patients care, the nurse should recognize the patients heightened risk of what complication? A)Venous thromboembolism B)Acute respiratory distress syndrome (ARDS) C)Myocardial infarction D)Hypertensive urgency

A - Patients with paroxysmal nocturnal hemoglobinuriahave a high incidence of life-threatening venous thrombosis, which occurs most commonly in the abdominal and cerebral veins. This health problem is not linked to ARDS, MI, or hypertensive urgency.

A patient is admitted for the treatment of a primary immunodeficiency and intravenous immunoglobulin (IVIG) is ordered. What should the nurse monitor for as a potential adverse effect of IVIG administration? A)Anaphylaxis B)Hypertension C)Hypothermia D)Joint pain

A - Potential adverse effects of an IVIG infusion include hypotension, flank pain, chills, and tightness in chest, terminating with a slightly elevated body temperature and anaphylactic reaction. Hypertension, hypothermia, and joint pain are not usual adverse effects of IVIG.

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 - Rigorous exercise or competitive exerciseusually considered a positive lifestyle factorcan 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 nurse is admitting a patient with an immunodeficiency to the medical unit. In planning the care of this patient, the nurse should assess for what common sign of immunodeficiency? A)Chronic diarrhea B)Hyperglycemia C)Rhinorrhea D)Contact dermatitis

A - The cardinal symptoms of immunodeficiency include chronic or recurrent severe infections, infections caused by unusual organisms or organisms that are normal body flora, poor response to treatment of infections, and chronic diarrhea. Hyperglycemia, rhinorrhea, and contact dermatitis are not symptoms the patient is likely to exhibit.

A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? A)Perianal region and oral mucosa B)Sacral region and lower abdomen C)Scalp and skin over the scapulae D)Axillae and upper thorax

A - The nurse should inspect all the patients skin surfaces and mucous membranes, but the oral mucosa and perianal region are particularly vulnerable to skin breakdown and fungal infection.

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 - 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

The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk? A)Providing thorough oral care before and after meals B)Administering prophylactic antibiotics C)Promoting nutrition and adequate fluid intake D)Applying skin emollients as needed

A - Thorough mouth care has the potential to prevent or limit the severity of this infection. Antibiotics are irrelevant because of the fungal etiology. The patient requires adequate food and fluids, but these do not necessarily prevent candidiasis. Skin emollients are not appropriate because candidiasis is usually oral.

A patients exposure to which of the following microorganisms is most likely to trigger a cellular response? A)Herpes simplex B)Staphylococcus aureus C)Pseudomonas aeruginosa D)Beta hemolytic Streptococcus

A - Viral, rather than bacterial antigens, induce a cellular response.

A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. A)Current medication regimen B)Identification of patients support system C)Immune system function D)Genetic risk factors for HIV E)History of sexual practices

A,B,C,E - Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function and sexual history. HIV does not have a genetic component.

A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A)Serum albumin level B)Weight history C)White blood cell count D)Body mass index E)Blood urea nitrogen (BUN) level

A,B,D,E - Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the patients ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment.

The nurse is applying standard precautions in the care of a patient who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. A)Using appropriate personal protective equipment B)Placing patients in negative-pressure isolation rooms C)Placing patients in positive-pressure isolation rooms D)Using safe injection practices E)Performing hand hygiene

A,D,E - Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions.

A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea? A)Zithromax B)Sandostatin C)Levaquin D)Biaxin

B - Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. Zithromax, Levaquin, and Biaxin are not used to treat chronic severe diarrhea.

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 - 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 patient diagnosed with common variable immune deficiency (CVID) has been admitted to the acute medicine unit. When reviewing this patients laboratory findings, the nurse should prioritize what values? A)Creatinine and blood urea nitrogen (BUN) B)Hemoglobin and vitamin B12 C)Sodium, potassium and magnesium D)D-dimer and c-reactive protein

B - A patient diagnosed with CVID often develops pernicious anemia; the patients hemoglobin and vitamin B12 levels would be used to assess for this common complication of CVID. None of the other listed blood values directly relates to the signs and complications of CVID.

A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy? A)Promoting appropriate use of complementary therapies B)Addressing possible barriers to adherence C)Educating the patient about the pathophysiology of HIV D)Teaching the patient about the need for follow-up blood work

B - ART is highly dependent on adherence to treatment, and the nurse should proactively address this. Blood work is necessary, but this will not have a direct bearing on the success or failure of treatment. Complementary therapies are appropriate, but are not the main factor in successful treatment. The patient may or may not benefit from teaching about HIV pathophysiology.

A nurse has administered a childs scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following? A)Natural immunity B)Active acquired immunity C)Cellular immunity D)Mild hypersensitivity

B - Active acquired immunity usually develops as a result of vaccination or contracting a disease. Natural immunity is present at birth and provides a nonspecific response to any foreign invader. Immunizations do not activate the process of cellular immunity. Hypersensitivity is not an expected outcome of immunization.

A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next? A)Flush the wound site with chlorhexidine. B)Report to the emergency department or employee health department. C)Apply a hydrocolloid dressing to the wound site. D)Follow up with the nurses primary care provider.

B - After initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. Flushing is recommended, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended. Following up with the nurses own primary care provider would require an unacceptable delay.

A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process? A)The cellular immune response B)Apoptosis C)Phagocytosis D)Opsonization

B - Apoptosis, or programmed cell death, is the bodys way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Opsonization is the coating of antigenantibody molecules with a sticky substance to facilitate phagocytosis. The body does not use phagocytosis or the cellular immune response to remove cells from circulation.

A patient is undergoing testing to determine the overall function of her immune system. What test can be performed to evaluate the functioning of the patients cellular immune system? A)Immunoglobulin testing B)Delayed hypersensitivity skin test C)Specific antibody response D)Total serum globulin assessment

B - Cellular (cell-mediated) immunity tests include the delayed hypersensitivity skin test, since this immune response is specifically dependent on the cellular immune response. Each of the other listed tests assesses functioning of the humoral immune system.

A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis? A)Acute Abdominal Pain B)Diarrhea C)Bowel Incontinence D)Constipation

B - Diarrhea is a problem in 50% to 60% of all AIDS patients. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply.

A patient is admitted with cellulitis and experiences a consequent increase in white blood cell count. The nurse is aware that during the immune response, pathogens are engulfed by white blood cells that ingest foreign particles. What is this process known as? A)Apoptosis B)Phagocytosis C)Antibody response D)Cellular immune response

B - During the first mechanism of defense, white blood cells, which have the ability to ingest foreign particles, move to the point of attack, where they engulf and destroy the invading agents. This is known as phagocytosis. The action described is not apoptosis (programmed cell death) or an antibody response. Phagocytosis occurs in the context of the cellular immune response, but it does not constitute the entire cellular response.

A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patients CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle? A)Integration B)Attachment C)Cleavage D)Budding

B - During the process of attachment, glycoproteins of HIV bind with the hosts uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle.

The nurse is admitting a patient to the unit with a diagnosis of ataxia-telangiectasia. The nurses assessment should reflect the patients increased risk for what complication? A)Peripheral edema B)Cancer C)Anaphylaxis D)Gastrointestinal bleeds

B - Frequent causes of death in patients with ataxia-telangiectasiaare chronic pulmonary disease and malignancy. Peripheral edema, anaphylaxis, and GI bleeding are not noted to be common among patients with ataxia-telangiectasia.

A nurse is caring for a patient with a phagocytic cell disorder. The patient states, My specialist says that I will likely be cured after I get my treatment tomorrow. To what treatment is the patient most likely referring? A)Treatment with granulocyte-macrophage colony-stimulating factor (GM-CSF) B)Hematopoietic stem cell transplantation C)Treatment with granulocyte colony-stimulating factor (G-CSF) D)Brachytherapy

B - Hematopoietic stem cell transplantation (HSCT), another form of cell therapy, has proven to be a successful curative modality. Treatment with GM-CSF or G-CSF is not curative. Brachytherapy is not a treatment for immunodeficiency.

A 20-year-old patient with an immunodeficiency is admitted to the unit with an acute episode of upper airway edema. This is the fifth time in the past 3 months that the patient has had such as episode. As the nurse caring for this patient, you know that the patient may have a deficiency of what? A)Interferons B)C1esterase inhibitor C)IgG D)IgA

B - Hereditary angioneurotic edema results from the deficiency of C1esterase inhibitor, which opposes the release of inflammatory mediators. The clinical picture of this autosomal dominant disorder includes recurrent attacks of edema. A patient with this diagnosis does not lack interferons, IgG, or IgA.

A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority? A)Oral temperature of 100F B)Tachypnea and restlessness C)Frequent loose stools D)Weight loss of 1 pound since yesterday

B - In prioritizing care, the pneumonia would be assessed first by the nurse. Tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 pound is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 100F is not considered a fever and would not be the first issue addressed.

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 - 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 6-month-old infant has been diagnosed with X-linked agammaglobulinemia and the parents do not understand why their baby did not develop an infection during the first months of life. The nurse should describe what phenomenon? A)Cell-mediated immunity in infants B)Passive acquired immunity C)Phagocytosis D)Opsonization

B - Infants with X-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins (passive acquired immunity), which occurs at about 5 to 6 months of age. Opsonization is the coating of antigenantibody molecules with a sticky substance to facilitate phagocytosis. Cell-mediated immunity and phagocytosis do not directly affect the timeline of the infants symptoms.

A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A)Appropriate use of prophylactic antibiotics B)Importance of personal hygiene C)Signs and symptoms of wasting syndrome D)Strategies for adjusting antiretroviral dosages

B - Infection control is of high importance in patients living with HIV, thus personal hygiene is paramount. This is a more important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be independently adjusted. Prophylactic antibiotics are not normally prescribed unless the patients CD4 count is below 50.

A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS? A)Risk for Disuse Syndrome Related to Kaposis Sarcoma B)Impaired Skin Integrity Related to Kaposis Sarcoma C)Diarrhea Related to Kaposis Sarcoma D)Impaired Swallowing Related to Kaposis Sarcoma

B - Kaposis sarcoma (KS) is a disease that involves the endothelial layer of blood and lymphatic vessels. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome.

A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this patient knows that the site of the injury will have an invasion of what? A)Interferons B)Phagocytic cells C)Apoptosis D)Cytokines

B - Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken glass. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. Apoptosis, or programmed cell death, is the bodys way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Cytokines are the various proteins that mediate the immune response. These do not migrate to injury sites.

A nurse is caring for a patient who has an immunodeficiency. What assessment finding should prompt the nurse to consider the possibility that the patient is developing an infection? A)Uncharacteristic aggression B)Persistent diarrhea C)Pruritis (itching) D)Constipation

B - Persistent diarrhea is among the varied signs and symptoms that may suggest infection in an immunocompromised patient. Aggression, pruritis, and constipation are less suggestive of an infectious etiology.

A nurse has created a plan of care for an immunodeficient patient, specifying that care providers take the patients pulse and respiratory rate for a full minute. What is the rationale for this aspect of care? A)Respirations affect heart rate in immunodeficient patients. B)These patients blunted inflammatory responses can cause subtle changes in status. C)Hemodynamic instability is one of the main complications of immunodeficiency. D)Immunodeficient patients are prone to ventricular tachycardia and atrial fibrillation.

B - Pulse rate and respiratory rate should be counted for a full minute, because subtle changes can signal deterioration in the patients clinical status. The rationale for this action is not because of the relationship between heart rate and respirations. These patients do not have a greatly increased risk of hemodynamic instability or dysrhythmias.

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 - 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 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 - 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.

A nurse has admitted a patient diagnosed with severe combined immunodeficiency disease (SCID) to the unit. The patients orders include IVIG. How will the patients dose of IVIG be determined? A)The patient will receive 25 to 50 mg/kg of body weight. B)The dose will be determined by the patients response. C)The dose will be determined by body surface area. D)The patient will receive a one-time bolus followed by 100- to 150-mg doses.

B - The optimal dosage of IVIG is determined by the patients response. In most instances, an IV dose of 200 to 800 mg/kg of body weight is administered.

A nurse is preparing to discharge a patient with an immunodeficiency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize? A)Sterile technique for establishing a new IV site B)Signs and symptoms of adverse reactions C)Formulas for calculating daily doses D)Technique for adding medications to the IVIG

B - The patient who is to receive IVIG at home will need information about adverse reactions and their management. A patient would not start a new IV site independently and the patient does not calculate changes in dose independently. Medications are not added to IVIG.

A patient is in the primary infection stage of HIV. What is true of this patients current health status? A)The patients HIV antibodies are successfully, but temporarily, killing the virus. B)The patient is infected with HIV but lacks HIV-specific antibodies. C)The patients risk for opportunistic infections is at its peak. D)The patient may or may not develop long-standing HIV infection.

B - The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection is certain. Opportunistic infections emerge much later in the course of the disease.

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 - 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 lymphocytes 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.

A young couple visits the nurse practitioner stating that they want to start a family. The husband states that his brother died of a severe infection at age 6 months. He says he never knew what was wrong but his mother had him undergo blood testing as a child. Based on these statements, what health problem should the nurse practitioner suspect? A)Severe neutropenia B)X-linked agammaglobulinemia C)Drug-induced thrombocytopenia D)Aplastic anemia

B - There is no evidence of drug-induced thrombocytopenia or aplastic anemia. The child would have only suffered from severe neutropenia if there was evidence of bacterial or fungal infections. The fact the mother of this individual had him tested for gamma-globulin as a child would indicate that his sibling had X-linked agammaglobulinemia. More than 10% of patients with X-linked agammaglobulinemia are hospitalized for infection at less than 6 months of age. Since the condition is X-linked it is important for the couple to undergo genetic testing.

A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions? A)Lifestyle actions that improve immune function B)Educational programs that focus on control and prevention C)Appropriate use of standard precautions D)Screening programs for youth and young adults

B - Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions apply to very few cases of HIV infection.

A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold? A)75 cells/mm3 of blood B)200 cells/mm3 of blood C)325 cells/mm3 of blood D)450 cells/mm3 of blood

B - When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.

A patient has been admitted with a phagocytic cell disorder and the nurse is reviewing the most common health problems that accompany these disorders. The nurse should identify which of the following? Select all that apply. A)Inflammatory bowel disease B)Chronic otitis media C)Cutaneous abscesses D)Pneumonia E)Cognitive deficits

B,C,D - Patients with phagocytic cell disorders experience recurrent cutaneous abscesses, chronic eczema, bronchitis, pneumonia, chronic otitis media, and sinusitis. Irritable bowel syndrome and cognitive deficits are atypical.

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 - 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 antigenantibody.

A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response? A)Do you think that you might already have HIV? B)Dont worry. Your immune system is likely very healthy. C)AIDS isnt transmitted by casual contact. D)You cant contract AIDS in a hospital setting.

C - AIDS is commonly transmitted by contact with blood and body fluids. Patients, family, and friends must be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV 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 - 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 an adolescent patient with a diagnosis of ataxia-telangiectasis. Which of the following nursing diagnoses should the nurse include in the patients plan of care? A)Fatigue Related to Pernicious Anemia B)Risk for Constipation Related to Decreased Gastric Motility C)Risk for Falls Due to Loss of Muscle Coordination D)Disturbed Kinesthetic Sensory Perception Related to Vascular Changes

C - Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular lesions caused by dilated blood vessels), and immune deficiency. Decreased coordination is likely to constitute a risk for falls. The patient does not characteristically lose tactile sensation or experience pernicious anemia or constipation.

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 - 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 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 - 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.

Diagnostic testing has revealed a deficiency in the function of a patients complement system. This patient is likely to have an impaired ability to do which of the following? A)Protecting the body against viral infection B)Marking the parameters of the immune response C)Bridging natural and acquired immunity D)Collecting immune complexes during inflammation

C - Complement has three major physiologic functions: defending the body against bacterial infection, bridging natural and acquired immunity, and disposing of immune complexes and the byproducts associated with inflammation. Complement does not mark the parameters of the immune response; complement does not collect immune complexes during inflammation.

A nurse caring for a patient who has an immunosuppressive disorder knows that continual monitoring of the patient is critical. What is the primary rationale behind the need for continual monitoring? A)So that the patients functional needs can be met immediately B)So that medications can be given as ordered and signs of adverse reactions noted C)So that early signs of impending infection can be detected and treated D)So that the nurses documentation can be thorough and accurate

C - Continual monitoring of the patients condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the patients status. Continual monitoring is not primarily motivated by the patients functional needs or medication schedule. The nurses documentation is important, but less than infection control.

A patients current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by what cells? A)Suppressor T cells B)Memory T cells C)Cytotoxic T cells D)Complement T cells

C - Cytotoxic T cells (also called CD8 + cells) participate in the destruction of foreign organisms. Memory T cells and suppressor T cells do not perform this role in the immune response. The complement system does not exist as a type of T cell.

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 - 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 with a diagnosis of primary immunodeficiency informs the nurse that he has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the patients vital signs are within reference ranges, what action should the nurse take? A)Administer a nebulized bronchodilator. B)Perform oral suctioning. C)Assess the patient for signs and symptoms of infection. D)Teach the patient deep breathing and coughing exercises.

C - Dyspnea and cough are among the many signs and symptoms that may suggest infection in an immunocompromised patient. There is no indication for suctioning or the use of nebulizers. Deep breathing and coughing exercises do not address the patients complaints or the likely etiology.

A patient with a diagnosis of common variable immunodeficiency begins to develop thick, sticky, tenacious sputum. The patient has a history of episodes of pneumonia at least one time per year for the last 10 years. What does the nurse suspect the patient is developing? A)Pulmonary edema B)A pulmonary neoplasm C)Bronchiectasis D)Emphysema

C - Frequent respiratory tract infections in patients with CVID typically lead to chronic progressive bronchiectasis and pulmonary failure. Pulmonary edema is often a result of vascular insufficiency. A patient suffering from CVID is likely to develop gastric cancer, not lung cancer. The patient is not at risk for emphysema.

A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors? A)The nurse wears face protection, gloves, and a gown when irrigating a wound. B)The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves. C)The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. D)The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.

C - Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same patient. Each of the other listed actions adheres to standard precautions.

A patients primary immunodeficiency disease is characterized by the inability of white blood cells to initiate an inflammatory response to infectious organisms. What is this patients most likely diagnosis? A)Chronic granulomatous disease B)Wiskott-Aldrich syndrome C)Hyperimmunoglobulinemia E syndrome D)Common variable immunodeficiency

C - In one rare type of phagocytic disorder, hyperimmunoglobulinemia E syndrome (formerly known as Job syndrome), white blood cells cannot initiate an inflammatory response to infectious organisms. The other listed health problems do not have this pathology.

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 - 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 - Many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones.

A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in AIDS patients by increasing body fat stores? A)Advera B)Momordicacharantia C)Megestrol D)Ranitidine

C - Megestrol acetate (Megace), a synthetic oral progesterone preparation, promotes significant weight gain. In patients with HIV infection, it increases body weight primarily by increasing body fat stores. Advera is a nutritional supplement that has been developed specifically for people with HIV infection and AIDS. Momordicacharantia (bitter melon) is given as an enema and is part of alternative treatment for HIV/AIDS. Ranitidine prevents ulcers.

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 - 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.

A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed diagnostic workup that reveals a phagocytic disorder. This patient faces an increased risk of what complication? A)Thrombocytopenia B)HIV/AIDS C)Neutropenia D)Hemophilia

C - Patients with phagocytic cell disorders may develop severe neutropenia. None of the other listed health problems is a common complication of phagocytic disorders.

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 - 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.

The nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency diseases? A)They require IVIG as treatment. B)They are the result of intrauterine infection. C)They have a genetic origin. D)They are communicable.

C - Primary immunodeficiency diseases are genetic in origin and result from intrinsic defects in the cells of the immune system. Primary immunodeficiency diseases do not always need IVIG as treatment, and they are not communicable. Primary immunodeficiencies do not result from intrauterine infection.

The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care? A)Maximize the patients fluid intake. B)Provide total parenteral nutrition (TPN). C)Keep the patients bed linens free of wrinkles. D)Provide the patient with snug clothing at all times.

C - Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Fluid intake should be adequate, and must be monitored, but maximizing fluid intake is not a goal. TPN is a nutritional intervention of last resort.

An immunocompromised patient is being treated in the hospital. The nurses assessment reveals that the patients submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurses most appropriate action? A)Administer a PRN dose of acetaminophen as ordered. B)Monitor the patients vital signs q2h for the next 24 hours. C)Inform the patients primary care provider of this finding. D)Implement standard precautions in the patients care.

C - Swollen lymph nodes are suggestive of infection and warrant prompt medical assessment and treatment. Acetaminophen is an ineffective response. The nurse should monitor the patients vital signs closely, but the physician should also be informed. Standard precautions should be in place regardless of the patients status.

A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse should expect the primary care provider to order what test to confirm the EIA test results? A)Another EIA test B)Viral load test C)Western blot test D)CD4/CD8 ratio

C - The Western blot test detects antibodies to HIV and is used to confirm the EIA test results. The viral load test measures HIV RNA in the plasma and is not used to confirm EIA test results, but instead to track the progression of the disease process. The CD4/CD8 ratio test evaluates the ratio of CD4 and CD8 cells but is not used to confirm results of EIA testing.

The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient? A)Would you like me to have the chaplain come speak with you? B)Youll learn much about the promise of a cure for HIV. C)Can you tell me what concerns you most about dying? D)You need to maintain hope because you may live for several years.

C - The nurse can help the patient verbalize feelings and identify resources for support. The nurse should respond with an open-ended question to help the patient to identify fears about being diagnosed with a life-threatening chronic illness. Immediate deferral to spiritual care is not a substitute for engaging with the patient. The nurse should attempt to foster hope, but not in a way that downplays the patients expressed fears.

A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? A)Complementary therapies generally have not been approved, so patients are usually discouraged from using them. B)Researchers have not looked at the benefits of alternative therapy for patients with HIV, so we suggest that you stay away from these therapies until there is solid research data available. C)Many patients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks. D)Youll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach.

C - The nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers. Complementary therapies and medical treatment are not mutually exclusive, though some contraindications exist. Research supports the efficacy of some forms of complementary and alternative treatment.

A home health nurse will soon begin administering IVIG to a new patient on a regular basis. What teaching should the nurse provide to the patient? A)The need for a sterile home environment B)Complementary alternatives to IVIG C)Expected benefits and outcomes of the treatment D)Technique for managing and monitoring daily fluid intake

C - The patient who is to receive IVIG at home will need information about the expected benefits and outcomes of the treatment as well as expected adverse reactions and their management. The home environment cannot be sterile and complementary alternatives to IVIG have not been identified. Fluid management is not a central concern.

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 - 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 primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following? A)Static stage B)Latent stage C)Viral set point D)Window period

C - The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though he or she is infected.

The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action? A)Assess the patient for additional signs and symptoms of Kaposis sarcoma. B)Review the patients most recent viral load and CD4+ count. C)Place the patient on respiratory isolation and inform the physician. D)Perform oral suctioning to reduce the patients risk for aspiration.

C - These signs and symptoms are suggestive of tuberculosis, not Kaposis sarcoma; prompt assessment and treatment is necessary. There is no indication of a need for oral suctioning and the patients blood work will not reflect the onset of this opportunistic infection.

The nurse is working with the interdisciplinary team to care for a patient who has recently been diagnosed with severe combined immunodeficiency disease (SCID). What treatment is likely of most benefit to this patient? A)Combined radiotherapy and chemotherapy B)Antibiotic therapy C)Hematopoietic stem cell transplantation (HSCT) D)Treatment with colony-stimulating factors (CSFs)

C - Treatment options for SCID include stem cell and bone marrow transplantation, but HSCT is the definitive therapy for the disease and supersedes the importance of antibiotics. CSFs, radiation therapy, and chemotherapy are not indicated.

A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient? A)Position the patient in the high Fowlers position whenever possible. B)Temporarily eliminate animal protein from the patients diet. C)Make sure the patient eats at least two servings of raw fruit each day. D)Obtain a stool culture to identify possible pathogens.

D - A stool culture should be obtained to determine the possible presence of microorganisms that cause diarrhea. Patients should generally avoid raw fruit when having diarrhea. There is no need to avoid animal protein or increase the height of the patients bed.

A nurse educator is explaining that patients with primary immunodeficiencies are living longer than in past decades because of advances in medical treatment. This increased longevity is associated with an increased risk of what? A)Chronic obstructive pulmonary disease B)Dementia C)Pulmonary fibrosis D)Cancer

D - Advances in medical treatment have meant that patients with primary immunodeficiencies live longer, thus increasing their overall risk of developing cancer. It does not mean that they are at increased risk of COPD, dementia, or pulmonary fibrosis.

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 - 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.

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 - 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.

A patient who has received a heart transplant is taking cyclosporine, an immunosuppressant. What should the nurse emphasize during health education about infection prevention? A)Eat a high-calorie, high-protein diet. B)Limit physical activity in order to conserve energy. C)Take prophylactic antibiotics as ordered. D)Perform frequent handwashing.

D - Hand hygiene is imperative in infection control. A well-balanced diet is important, but for most patients this is secondary to hygiene as an infection-control measure. Prophylactic antibiotics are not normally used. Limiting physical activity will not protect the patient from infection.

A nurse is planning the care of a patient who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this patient? A)Administration of IVIG B)Antibiotic administration C)Appropriate use of gloves and goggles D)Thorough and consistent hand hygiene

D - Hand hygiene is usually considered the most important aspect of infection control. IVIG and antibiotics are not considered infection control measures, though they enhance resistance to infection and treat infection. Gloves and goggles are sometimes indicated but are less effective than hand hygiene.

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 - 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 current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide based on the patients medication regimen? A)Avoid high-fat meals while taking this medication. B)Limit fluid intake to 2 liters a day. C)Limit sodium intake to 2 grams per day. D)Take this medication without regard to meals.

D - Many NRTIs exist, but all of them may be safely taken without regard to meals. Protein, fluid, and sodium restrictions play no role in relation to these drugs.

A nurse is providing health education regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize? A)The importance of aggressive treatment of acne B)The importance of avoiding alcohol-based cleansers C)The need to keep fingernails and toenails closely trimmed D)The need for thorough oral hygiene

D - Many patients develop oral manifestations and need education about promoting good dental hygiene to diminish the oral discomfort and complications that frequently result in inadequate nutritional intake. Alcohol cleansers do not necessarily need to be avoided and nail care is not a central concern. Acne care is not a main focus of education, since it is not relevant to many patients.

A nurse has admitted a patient who has been diagnosed with urosepsis. What immune response predominates in sepsis? A)Mitigated B)Nonspecific C)Cellular D)Humoral

D - Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. For example, during transplantation rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant role. Neither mitigated nor nonspecific cell response is noted in this situation.

An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurses best response? A)There is no way to know that for certain, but we do know that your baby has a one in four chance of being born with HIV. B)Your physician is likely the best one to ask that question. C)If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to worry about it now. D)Its possible that your baby could contract HIV, either before, during, or after delivery.

D - Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breast-feeding. There is no evidence that the infants risk is 25%. Deferral to the physician is not a substitute for responding appropriately to the patients concern. Downplaying the patients concerns is inappropriate.

A neonate exhibited some preliminary signs of infection, but the infants condition resolved spontaneously prior to discharge home from the hospital. This infants recovery was most likely due to what type of immunity? A)Cytokine immunity B)Specific immunity C)Active acquired immunity D)Nonspecific immunity

D - Natural immunity, or nonspecific immunity, is present at birth. Active acquired or specific immunity develops after birth. Cytokines are proteins that mediate the immune response; they are not a type of immunity.

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 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.

A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurses best response? A)Theres no way to be sure you wont get HIV except to use condoms correctly. B)Only the correct use of a female condom protects against the transmission of HIV. C)There are new ways of protecting yourself from HIV that are being discovered every day. D)Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV.

D - Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual transmission of HIV infection. Both female and male condoms confer significant protection. New prevention techniques are not commonly discovered, though advances in treatment are constant.

A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what? A)The patient is immune to HIV. B)The patients immune system is intact. C)The patient has AIDS-related complications. D)The patient has been infected with HIV.

D - Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications.

A nursing student is giving a report on the immune system. What function of cytokines should the student describe? A)Determining whether a cell is foreign B)Determining if lymphokines will be activated C)Determining whether the T cells will remain in the nodes and retain a memory of the antigen D)Determining whether the immune response will be the production of antibodies or a cell-mediated response

D - Separate subpopulations of helper T cells produce different types of cytokines and determine whether the immune response will be the production of antibodies or a cell-mediated immune response. Cytokines do not determine whether cells are foreign, determine if lymphokines will be activated, or determine the role of memory T cells.

The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees? A)Attach the condom prior to erection. B)A condom may be reused with the same partner if ejaculation has not occurred. C)Use skin lotion as a lubricant if alternatives are unavailable. D)Hold the condom by the cuff upon withdrawal.

D - The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, or cold cream should not be used with condoms because they cause latex deterioration/condom breakage. The condom should be held during withdrawal so it does not come off the penis. Condoms should never be reused.

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 - 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 bacterial pneumonia. In the first stages of illness, the patients dyspnea was accompanied by a high fever. Currently, the patient claims to be feeling better and is afebrile. The patient is most likely in which stage of the immune response? A)Recognition stage B)Proliferation stage C)Response stage D)Effector stage

D - The immune response culminates with the effector stage, during which offending microorganisms are killed by the various actions of the immune system. The patients improvement in health status is likely the result of this final stage in the immune response.

The nurse is preparing to administer IVIG to a patient who has an immunodeficiency. What nursing guideline should the nurse apply? A)Do not exceed an infusion rate of 300 mL/hr. B)Slow the infusion rate if the patient exhibits signs of a transfusion reaction. C)Weigh the patient immediately after the infusion is complete. D)Administer pretreatment medications as ordered 30 minutes prior to infusion.

D - The nurse should administer pretreatment acetaminophen and diphenhydramine as prescribed 30 minutes before the start of the infusion. The patient should be weighed prior to the treatment and the IV infusion rate should not exceed 200 mL/hour. The nurse should stop the transfusion in the event of any signs of a reaction.

IVIG has been ordered for the treatment of a patient with an immunodeficiency. Which of the following actions should the nurse perform before administering this blood product? A)Ensure that the patient has a patent central line. B)Ensure that the IVIG is appropriately mixed with normal saline. C)Administer furosemide before IVIG to prevent hypervolemia. D)Weigh the patient before administration to verify the correct dose.

D - The nurse should obtain height and weight before treatment to verify accurate dosing. IVIG can be administered through a peripheral line. Diuretics are not normally given prior to administration, and IVIG is not mixed with normal saline.

A home health nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurses teaching? A)My family needs to understand when I can go get the seasonal flu shot. B)I need to know how to treat my infections in a home setting. C)I need to understand how to give my platelet transfusions. D)My family needs to understand that Ill probably need lifelong treatment.

D - The patient must be made aware that all health-related instructions are lifelong. Immunizations may be contraindicated and infection usually requires inpatient treatment. Platelet transfusions are not indicated for most patients who have immunodeficiencies.

During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection? A)Salmonella infection B)Mycobacterium tuberculosis C)Clostridium difficile D)Pneumocystis pneumonia

D - There are a number of opportunistic infections that can infect individuals with AIDS. The most common life-threatening infection in those living with AIDS is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly carinii). Other opportunistic infections may involve Salmonella,Mycobacterium tuberculosis, and Clostridium difficile.

The home health nurse is assessing a patient who is immunosuppressed following a liver transplant. What is the most essential teaching for this patient and the family? A)How to promote immune function through nutrition B)The importance of maintaining the patients vaccination status C)How to choose antibiotics based on the patients symptoms D)The need to report any slight changes in the patients health status

D - They must be informed of the need for continuous monitoring for subtle changes in the patients physical health status and of the importance of seeking immediate health care if changes are detected. Nutrition is important, but infection control is the priority. Patients and families do not choose antibiotics independently. Vaccinations are often contraindicated in immunocompromised patients.

The parents of a 1-month-old infant bring their child to the pediatrician with symptoms of congestive heart failure. The infant is ultimately diagnosed with DiGeorge syndrome. What will prolong this infants survival? A)Stem cell transplantation B)Long-term antibiotics C)Chemotherapy D)Thymus gland transplantation

D - Transplantation of fetal thymus, postnatal thymus, or human leukocyte antigen (HLA)-matched bone marrow has been used for permanent reconstitution of T-cell immunity in infants with DiGeorge syndrome. Antibiotics and chemotherapy do not address the etiology of the infants disease. Stem cell transplantation is not a common treatment modality.