WK 5 PrepU Nurs 242
Which of the following is a age-related change associated with the immune system?
Decreased antibody production Explanation: Age-related changes associated with the immune response include decreased antibody production, suppressed phagocytic immune response, and a failure of immune system to differentiate "self" from "nonself."
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?
"Avoid sharing such articles as toothbrushes and razors." Explanation: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS.
A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?
Engulfment and digestion of bacteria and foreign material Explanation: Phagocytosis is the process of engulfing and digesting bacteria and foreign materials. It does not involve the release of chemicals or conversion of memory cells to plasma cells. The macrophages in the spleen remove bacteria and dead blood cells from circulation.
Client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What action is of primary importance upon admission?
maintain airway Explanation: Anaphylaxis is a rapid, profound hypersensitivity response. A massive release of histamine causes vasodilation, increased capillary permeability, angioneurotic edema (acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs), hypotension, and bronchoconstriction. In an emergency, the primary focus of care is maintaining the airway.
A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse?
"The doctor could prescribe anti-inflammatory drugs." Explanation: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Antipyretic and antihypertensive drugs are not prescribed for autoimmune diseases. An antineoplastic drug is not ordered for an autoimmune disorder until it is in its late stages and uncontrolled by the first-line drugs.
A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells?
Epoetin alfa (Epogen) Explanation: Colony-stimulating factors are cytokines that prompt the bone marrow to produce, mature, and promote the functions of blood cells. CSFs enable stem cells in bone marrow to differentiate into specific types of cells such as leukocytes, erythrocytes, and platelets. Pharmacologic preparation of CSFs, such as epoetin alfa (Epogen), is used to promote the natural production of blood cells in people whose own hematopoietic functions have become compromised. The other medications in A, B, and D are tumor necrosis factor inhibitors.
A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?
"I understand your concern. The blood is screened very carefully for different viruses as well as HIV." Explanation: Blood and blood products can transmit HIV to recipients. However, the risk associated with transfusions has been virtually eliminated as a result of voluntary self-deferral, completion of a detailed health history, extensive testing, heat treatment of clotting factor concentrates, and more effective virus inactivation methods. Donated blood is tested for antibodies to HIV-1, human immunodeficiency virus type 2 (HIV-2), and p24 antigen; in addition, since 1999, nucleic acid amplification testing (NAT) has been performed.
A client is to receive intravenous immunoglobulin (IVIG). The infusion is started at 10 a.m. The nurse would be alert for signs and symptoms of an anaphylactic reaction during which time frame?
10:30 to 11:00 a.m. Explanation: When administering IVIG, anaphylactic reactions typically occur 30 to 60 minutes after the start of the infusion. Therefore, the time frame would be 10:30 to 11:00 a.m.
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?
Acquired immunity Explanation: 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.
Which of the following is the most severe form of hypersensitivity reaction?
Anaphylaxis Explanation: The most severe form of hypersensitivity reaction or immune-mediated reaction is anaphylaxis. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Type III, or immune complex, hypersensitivity involves immune complexes that are formed when antigens bind to antibodies. Type IV, or delayed-type hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.
A client presents to the clinic with complaints that he began to itch and break out in hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?
Diphenhydramine Explanation: Diphenhydramine is an antihistamine which blocks histamine receptors and is used for allergic reactions. Flunisolide is a nasal decongestant agent and is used locally to the nasal mucosa. Beclomethasone dipropionate is a nasal steroid spray and inhalant. Pseudoephedrine hydrochloride only constricts nasal membranes.
Which cells present the antigen to T cells and initiate the immune response?
Macrophages Explanation: Macrophages initiate the immune response. B cells are programmed to produce one specific antibody. Antigens are substances that induce the production of antibodies. Haptens are incomplete antigens.
The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?
Palpation of the client's lymph nodes Explanation: 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 client is suspected to have an immunodeficiency disorder. The health care provider orders a nitroblue tetrazolium reductase (NTR) test to diagnose this client. What does the nurse suspect that this disorder is related to?
Phagocytic cells Explanation: Diagnosis of phagocytic cell disorders is based on the history, signs, and symptoms, and laboratory analysis by the nitroblue tetrazolium reductase test, which indicates the cytocidal (causing death of cells) activity of the phagocytic cells.
A patient is admitted with an infected leg, and the nurse notes an increase in his white blood cell (WBC) count. The nurse is aware that, during the immune response, pathogens are engulfed by WBCs that ingest foreign particles. What is this process known as?
Phagocytosis Explanation: During the first mechanism of defense, WBCs, 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, antibody response, or a cellular immune response.
A client is diagnosed with multiple site cancers and has received whole-body irradiation. The nurse is concerned about a compromised immune system in this client for which reason?
Radiation destroys lymphocytes. Explanation: Radiation destroys lymphocytes and decreases the ability to mount an effective immune response. Radiation is not associated with an excess of lymphocytes or an excess or deficiency of hemoglobin.
What are the primary participants in the immune system?
T- and B- cell lymphocytes Explanation: Lymphocytes, which are either T-cell or B-cell lymphocytes, comprise 20% to 30% of all leukocytes. T-cell and B-cell lymphocytes are the primary participants in the immune response. Therefore options A, C, and D are incorrect.
The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?
T-cell lymphocytes survey proteins in the body and attack the invading antigens. Explanation: During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their toxins through agglutination or by causing them to precipitate.
Ataxia refers to
uncoordinated muscle movement. Explanation: Ataxia-telangiectasia is an autosomal recessive disorder affecting both T-cell and B-cell immunity. Telangiectasia refers to vascular lesions caused by dilated blood vessels. Receptive aphasia is an inability to understand spoken words. Dysphagia refers to difficulty swallowing.
During a routine checkup, a nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?
Kaposi's sarcoma Explanation: Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS.
The nurse is obtaining a history from a patient with severe psoriasis. What question would be the most important to ask this patient to determine a genetic predisposition?
"Does anyone in your family have more than one autoimmune disease?" Explanation: The patient is asked about any autoimmune disorders, such as lupus erythematosus, rheumatoid arthritis, multiple sclerosis, or psoriasis. The onset, severity, remissions and exacerbations, functional limitations, treatments that the patient has received or is currently receiving, and effectiveness of the treatments are described. The occurrence of different autoimmune diseases within a family strongly suggests a genetic predisposition to more than one autoimmune disease (Brooks, 2010) (Chart 35-4).
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Explanation: Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells-those cells that are "self." Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.
A nurse has given a child's scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following?
Active acquired immunity Explanation: 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.
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?
Airway obstruction Explanation: Injectants, such as bee venom, and some other allergens can produce systemic and potentially fatal effects, including shock and airway obstruction caused by laryngeal swelling. Although all other answers can occur with an allergen, they are not the most serious complication.
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
Apply an allergy bracelet and flag the chart. Explanation: The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?
Artificially acquired active immunity Explanation: Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid. Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection . Not all invading microorganisms produce a response that gives lifelong immunity. There is not a type of immunity called forced immunity.
The client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?
Avoid antihistamines and cold preparations for 48 to 72 hours before the test. Explanation: The nurse should instruct the client to avoid taking prescribed or over-the-counter antihistamine or cold preparations for at least 48 to 72 hours before a skin test because this reduces the potential for false-negative test results. The nurse should not ask the client to avoid red meat, strenuous physical activity, or sunlight because these do not affect the test results.
The nurse is administering a sympathomimetic drug to a patient. What areas of concern does the nurse have when administering this drug? (Select all that apply.)
Causes bronchodilation Constricts integumentary smooth muscle Dilates the muscular vasculature Explanation: The patient must be aware of the effects caused by overuse of the sympathomimetic agents in nose drops or sprays, because a condition referred to as rhinitis medicamentosa may result. After topical application of the medication, a rebound period occurs in which the nasal mucous membranes become more edematous and congested than they were before the medication was used.
The nurse is caring for an older client admitted to the health-care facility with a new onset of confusion and a low-grade fever. Which age-related changes might contribute to decreased functioning of the immune system?
Decreased kidney function Explanation: Decreased kidney function, changes in lower urinary tract function (enlargement of the prostate), and altered genitourinary tract flora all contribute to increased urinary tract infections. With age, the skin thins, gastric secretions decrease, and ciliary action decreases.
A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?
Delayed hypersensitivity response Explanation: A delayed hypersensitivity response may develop over several hours or days, or it may reach maximum severity after repeated exposure. Examples of a delayed hypersensitivity response include a blood transfusion reaction that occurs days to weeks after blood administration, rejection of transplanted tissues, and reaction to a tuberculin skin test. Anaphylaxis is a rapid and profound type I hypersensitivity response. Sensitization is the process by which cellular and chemical events occur after a second or subsequent exposure to an allergen. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly.
The nurse is conducting an assessment on a client that has a latex allergy. What signs and symptoms would the nurse expect to see upon assessment? Select all that apply.
Flushing Conjunctivitis Explanation: Thick skin is a chronic symptom of irritant contact dermatitis. Flushing is a sign/symptom of latex allergy. Blisters are symptoms of allergic contact dermatitis. Conjunctivitis is a sign/symptom of latex allergy. Urticaria is a sign/symptom of latex allergy. Reference: Brunner & Suddarth. Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients with Allergic Disorders, p. 1080. Table 37-6.
A nurse is caring for a client diagnosed with human immunodeficiency virus (HIV). The client wants to know when medication for the disease will begin. What is the nurse's best response?
If the client has a CD4 T-cell count less than 350 cells/mm3. Explanation: The current guideline is to initiate treatment if the client develops an AIDS-defining illness or has a CD4 T-cell count less than 350 cells/mm3. Antiretroviral drug therapy is also warranted in infected pregnant women, in clients with HIV-associated renal disease, and in clients coinfected with hepatitis B. Options B, C, and D are therefore incorrect.
A nurse is planning the care of a client with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client?
Ineffective Airway Clearance Explanation: Although all these nursing diagnoses are appropriate for a client with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the client with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns because of the immediacy of the health consequences.
While caring for a patient with pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate?
Kaposi's sarcoma Explanation: Kaposi's sarcoma, the most common HIV-related malignancy, is a disease that involves the endothelial layer of blood and lymphatic vessels. Cutaneous signs may be the first manifestation of HIV; they can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymoses (hemorrhagic patches) and edema (Fig. 37-3).
Which group of mediators initiates the inflammatory response?
Leukotrienes Explanation: Leukotrienes are a group of chemical mediators that initiate the inflammatory response. Lymphokines are substances released by sensitized lymphocytes when they contact specific organs. Mast cells are connective tissue that contains heparin and histamine in their granules. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activity.
A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
Listen and show interest as the client expresses feelings. Explanation: The nurse should listen actively and nonjudgmentally as the client expresses feelings. Telling the client not to worry would provide false reassurance. A psychiatric consultation would be appropriate only after further assessment. Stating that the client's friends aren't true friends would discount the client's feelings.
The nurse is caring for a client with a suspected diagnosis of HIV. The nurse is preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV?
Obtain a written consent from the client. Explanation: It is important that the nurse obtain written consent from the client before performing an HIV test and keep the results of HIV test confidential. The nurse may not ask the client to avoid excess fluid intake or abstain from intercourse before the tests. The client also need not take off ornaments and metallic objects worn unless they are likely to interfere with the test results.
A client with Crohn's disease, an autoimmune disorder, informs the nurse that he has not had any symptoms of the disease in 8 months. What does the nurse understand this asymptomatic period is referred to?
Remission Explanation: Periods of remission refer to times when the client has no symptoms. The duration of these periods is completely unpredictable. An exacerbation is periods of acute flare-ups when the client often experiences a low-grade fever, malaise, or fatigue. He may also lose weight. Other symptoms such as pain and diarrhea can be associated with a flare-up of Crohn's disease. The client is not having an acute inflammatory response that would be considered an exacerbation.
When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?
Risk for infection related to altered immune cell function Explanation: Although anxiety and impaired skin integrity may be appropriate, the priority nursing diagnosis for any immunodeficiency is the risk for infection. Although primary immunodeficiencies can be serious, they are rarely fatal. Therefore, the nursing diagnosis of grieving would be inappropriate.
A nurse is completing a nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
Serum albumin level Weight history Body mass index Blood urea nitrogen (BUN) level Explanation: 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 client's 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.
A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions?
Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens. Explanation: Standard precautions are designed to reduce the risk of transmission of bloodborne pathogens and of pathogens from moist body substances. Standard precautions are used when working with all patients in all health care settings, regardless of their diagnosis or presumed infectious status (Siegel, Rhinehart, Jackson, et al., 2007).
A parent brings a young child to the clinic for an evaluation of an infection. The parent states, "my child has been taking antibiotics now for more than 2 months and still doesn't seem any better." During the history and physical examination, what would alert the nurse to suspect a primary immunodeficiency?
Ten ear infections in the past year Explanation: The parent has already reported one of the warning signs associated with primary immunodeficiencies--the use of antibiotics for 2 or more months with little effect. Another warning sign is eight or more new ear infections within 1 year. Therefore, the report of 10 ear infections in the past year would increase the nurse's suspicion. Recurrent, deep skin, or organ abscesses, failure of an infant to gain weight or grow normally, and persistent thrush (yeast infection) in the mouth or elsewhere on the skin after age 1 year would be additional warning signs. A superficial wound on the leg, age-appropriate weight, and a history of a fungal diaper rash would not be considered warning signs.
A client on antiretroviral drug therapy is discussing with the nurse that sometimes he "forgets to take his meds for a few days." What should the nurse inform the client can occur when the medications are not taken as prescribed?
The client is risking the development of drug resistance and drug failure. Explanation: Clients who neglect to take antiretroviral drugs as prescribed risk development of drug resistance. When drug levels are not adequately maintained, viral replication and mutations increase. Noncompliant clients are one cause of antiretroviral drug therapy. Funding will not cease for noncompliance. The medications are not all available in IV form.
A client suspected of having human immunodeficiency virus (HIV) asks the nurse what causes AIDS. What is the best response by the nurse?
The human immunodeficiency virus Explanation: A pathogen known as the human immunodeficiency virus (HIV) causes AIDS. HIV/AIDS is not caused by either the streptococcal or the staphylococcal bacteria; it is also not caused by the Epstein-Barr virus.
A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection?
Through the mucous membranes of the throat Explanation: In a streptococcal throat infection, the streptococcal organism gains access to the mucous membranes of the throat.
When the nurse administers intravenous gamma-globulin infusion, she recognizes that which symptom, if reported by the client, may indicate an adverse effect of the infusion?
Tightness in the chest Explanation: Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion. Nasal stuffiness and increased thirst are not recognized as adverse effects of gamma-globulin infusion. Burning urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.
Atopic allergic disorders are characterized by
a hereditary predisposition. Explanation: Atopic allergic disorders are characterized by a hereditary predisposition and production of a local reaction to IgE antibodies produced in response to common environmental allergens. Atopic and nonatopic allergic disorders are IgE-mediated allergic reactions.
A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate?
candidiasis Explanation: Candidiasis is a yeast infection caused by the Candida albicans microorganisms. It may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in folds of the skin. It is often called thrush when located in the mouth. Inspection of the mouth, throat, or vagina reveals areas of white plaque that may bleed when mobilized with a cotton-tipped swab. Kaposi's sarcoma is a purple lesion and is an opportunistic cancer. Hairy leukoplakia is also an indication of oral cancer. Coccidioidomycosis causes diarrhea in the immunosuppressed client.
After teaching a client with immunodeficiency about ways to prevent infection, the nurse determines that teaching was successful when the client makes which statement?
"I should avoid being around other people who have an infection." Explanation: Strategies to prevent infection include avoiding being around others who have an infection and avoiding crowds. The client should avoid consumption of raw fruits and vegetables and use creams and emollients to prevent or manage dry, chafed, or cracked skin. A disinfectant, not just hot water, should be used to clean kitchen and bathroom surfaces.
A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse?
"It is important that you continue to take your medication to avoid an acute exacerbation." Explanation: Even with remission, most people must continue taking prescribed medications to avoid another acute exacerbation. The client should be encouraged to maintain the therapeutic regimen in order to avoid an exacerbation and prolong the period of remission as long as possible. If the client is considering the discontinuation of the medication, he should notify the physician prior. The nurse is not at liberty to allow the client to discontinue medication use. Informing the client he will become ill if he discontinues the medication does not inform them of the rationale.
What organ is considered lymphoid tissue?
Spleen Explanation: Lymphoid tissues, such as the thymus gland, tonsils and adenoids, spleen, and lymph nodes, play a role in the immune response and prevention of infection. The pancreas, intestines, and liver are not lymphoid tissue.
Thirty minutes after the nurse begins an intravenous immunoglobulin (IVIG) infusion, the client reports itching at the site and a lump in the throat. Which action should the nurse take first?
Stop the infusion. Explanation: Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat as the precursor to laryngospasm that precedes bronchoconstriction. Stop the infusions at the first sign of reaction and initiate the institutional protocol to be followed in this emergent situation.
A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following?
The client's immune system cannot mount a response to the skin test. Explanation: The inflammatory response is a major function of the immune system that is elicited in response to invading foreign material. A person with AIDS has a poorly functioning or non-functioning immune system that will not respond to the injected skin test. Any TB organisms should cause a reaction to the skin test in people with intact immune systems. The nurse cannot accurately speculate on how the skin test was performed or that the solution was outdated.
A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder?
The immune system recognizes one's own tissues as "foreign." Explanation: The immune system's recognition of one's own tissues as "foreign" rather than self is the basis of many autoimmune disorders, including multiple sclerosis. When regulatory mechanisms fail to halt the immune response or excess cytokines are produced, pathology occurs (e.g., allergies, hypersensitivity).
Why would it be important for the nurse to question the client about sexual practices, history of substance abuse, and his lifestyle during the interview process?
To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS) Explanation: The nurse investigates the client's allergy history and questions the client about practices that put him or her at risk for AIDS. The interview will not determine the client's ability to be compliant. The physician would make the determination if a counseling referral should be made. It is irrelevant to determine the personality traits in the initial interview.
A patient tells the nurse, "I can't believe I have ineffective immune function and am getting sick again. I exercise rigorously and compete regularly." What is the best response by the nurse?
"Rigorous exercise can cause negative effects on immune response." Explanation: Although factors that are not consistent with a healthy lifestyle are predominately responsible for ineffective immune function, positive lifestyle factors can also negatively affect immune function and require assessment. For example, rigorous exercise or competitive exercise— usually considered a positive lifestyle factor—can be a physiologic stressor and cause negative effects on immune response (Walsh, Gleeson, Shephard, et al., 2011).
A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse?
"These tissues filter bacteria from tissue fluid." Explanation: Tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral cavity, they can become infected and locally inflamed. The spleen acts as an emergency reservoir of blood and removes blood and bacteria, not the tonsils.
A client who has been exposed to the human immunodeficiency virus (HIV) tests negative. Which explanation by the nurse would be most appropriate?
"Your body may not have developed antibodies yet, so we need to follow up." Explanation: A negative test result means that antibodies to HIV are not in the blood at this time. The person may not be infected or the person's body may not yet have produced antibodies. (The "window" period is 3 weeks to 6 months). The client needs follow-up testing and must continue to take precautions. The negative test result does not mean that the client is immune to HIV, nor does it mean that the client is not infected. It just means that the body may not have produced antibodies yet.
A client is to self-administer intravenous immunoglobulin (IVIG) in the home. What is the client's first action?
Check the IV device patency. Explanation: When administering intravenous immunoglobulin in the home, it is imperative to ensure that the IV access device is patent. This should be done first because if the device is not patent, it would be useless to prepare the solution, administer the premedication, or check vital signs. Unless the device is patent, the medication could not be given.