Ch. 33
The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis? A) The client will have a productive cough. B) The injection area swells if the client has developed antibodies against the antigen. C) The injection area will become painful with induration if the client has antibodies against the antigen. D) The injection area will break out in a fine macular rash.
Ans: B Feedback: The injection area swells if the client has developed antibodies against the antigen. The client is not necessarily actively infectious if the test results are positive. Although a productive cough is one of the symptoms of active tuberculosis, it may also indicate other diseases and disorders. The area should not be painful, and the client should not break out with a rash.
A client has dilated cardiomyopathy and has just found out he will be receiving a heart. What medication does the client understand that he will have to take for the duration of his life to help suppress the immune system to prevent rejection of the new heart? A) Infliximab (Remicade) B) Etanercept (Enbrel) C) Adalimumab (Humira) D) Cyclosporine (Sandimmune)
Ans: D Feedback: After organ transplantation, the client's immune system may attack the new organ's cells because it recognizes them as nonself. Cyclosporine is used to intentionally suppress the immune system. The medications in A, B, and C are all used to suppress inflammation.
A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used? A) The taste of the medication is not palatable. B) The medication will work more rapidly parenterally. C) The medication, given orally, will cause diarrhea. D) Digestive enzymes destroy its protein structure.
Ans: D Feedback: Interferon is administered parenterally because digestive enzymes destroy its protein structure. The medicine does not have an oral preparation.
You are the clinic nurse caring for a client with a suspected diagnosis of HIV. You are 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? A) Advise the client to avoid excess fluid intake. B) Advise the client to abstain from having intercourse. C) Advise the client to take off any ornaments and metallic objects. D) Obtain a written consent from the client.
Ans: D Feedback: 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.
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system? A) Stem cells B) Cytokines C) Lymphoid tissues ) Red blood cells
Ans: C Feedback: The immune system actually is a collection of specialized white blood cells and lymphoid tissues that cooperate to protect a person from external invaders and the body's own altered cells. The function of these structures is assisted and supported by the activities of natural killer cells, antibodies, and nonantibody proteins such as cytokines and the complement system. Red blood cells and stem cells are not part of the immune system.
What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction? A) IgG B) IgA C) IgM D) IgE
Ans: D Feedback: IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reaction. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.
A client has had mumps when he was 9 years old. He had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect? A) Artificially acquired active immunity B) Naturally acquired active immunity C) Passive immunity D) Natural passive immunity
Ans: B Feedback: 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. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid. Passive immunity is acquired when ready-made antibodies are given to a susceptible person.
The nurse is instructing client's about the importance of taking the shingles vaccine. Which client would benefit from this vaccine? A) A 24-year-old client who is pregnant B) A 17-year-old client who will be attending college and living in a dormitory C) A 32-year-old client who has never had chickenpox D) A 65-year-old client who had chicken pox when he was 12 years old
Ans: D Feedback: Half of individuals living to age 65 years have had or will develop shingles and may not understand the potential seriousness and risk for complications. Nurses as client advocates should determine and provide health information regarding the shingles vaccine. The other clients are not candidates for the vaccine.
The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response? A) Ibuprofen (Advil) B) Angiotensin-converting enzyme inhibitors (ACE-I) C) Diuretics D) Corticosteroids
Ans: D Feedback: The nurse obtains a history of immunizations, recent and past infectious diseases, and recent exposure to infectious diseases. He or she reviews the client's drug history because certain drugs, such as corticosteroids, suppress the inflammatory and immune responses. Advil is a nonsteroidal anti-inflammatory medication and does not suppress the inflammatory and immune responses. An ACE-I prevents the conversion of angiotensin I to angiotensin II and does not suppress the inflammatory or immune response. Diuretics also do not suppress the immune response but help reduce excess fluid from the kidneys.
A client will be taking the tumor necrosis factor inhibitor, infliximab (Remicade), for the treatment of rheumatoid arthritis. Prior to beginning this therapeutic regimen, what screening should the client have? A) Screening for tuberculosis B) Screening for peptic ulcer disease C) Screening for syphilis D) Screening for rubella
Ans: A Feedback: Before prescribing a TNF inhibitor, clients should be screened for tuberculosis because there is a risk for activating latent tuberculosis. It is not necessary to screen for peptic ulcer disease, syphilis, or rubella prior to beginning TNF inhibitor therapy.
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection? A) Naturally acquired active immunity B) Artificially acquired active immunity C) Naturally acquired passive immunity D) Artificially acquired passive immunity
Ans: A Feedback: Immunity to measles that develops after the initial infection is an example of naturally acquired active immunity. Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated toxin), whereas passive immunity develops when ready-made antibodies are given to a susceptible client.
You are caring for a client with a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected? A) Protein electrophoresis B) Enzyme-linked immunosorbent assay C) T-cell and B-cell assays D) Plasmapheresis
Ans: A Feedback: When an immune system disorder is suspected, protein electrophoresis screens for diseases associated with a deficiency or excess of immunoglobulins may be ordered. Options B, C, and D are incorrect tests to diagnose a deficiency or excess of immunoglobulins.
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide? A) Forced immunity B) Naturally acquired active immunity C) Passive immunity D) Artificially acquired active immunity
Ans: D Feedback: 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.
What is the function of the thymus gland? A) Produces stem cells B) Programs B lymphocytes to become regulator or effector B cells C) Develops the lymphatic system D) Programs T lymphocytes to become regulator or effector T cells
Ans: D Feedback: The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum. The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle. Options A, B, and C are incorrect.
A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse? A) "White blood cells are produced in the plasma." B) "White blood cells are produced in the thymus gland." C) "White blood cells are produced in the lymphatic tissue." D) "White blood cells are produced in the bone marrow."
Ans: D Feedback: White blood cells (leukocytes) are produced in the bone marrow. They are not produced in the plasma, thymus gland, or the lymphatic tissue.
The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells? A) Natural killer cells B) Cytokines C) Interleukins D) Interferons
Ans: A Feedback: Natural killer cells are lymphocyte-like cells that circulate throughout the body looking for virus-infected cells and cancer cells. Cytokines are chemical messengers released by lymphocytes, monocytes, and macrophages. Interleukins carry messages between leukocytes and tissues that form blood cells. Interferons are chemicals that primarily protect cells from viral infections.
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health? A) The client appears mildly ill, listless, and disheveled. B) The client has a blood pressure of 120/72 mm Hg. C) The client is alert and oriented to all spheres. D) The client has palpable peripheral pulses in the upper extremities.
Ans: A Feedback: The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then performs a more comprehensive examination.
A client has not responded to chemotherapy and radiation therapy. What option may be available for treatment for this client? A) If chemotherapy and radiation do not work, there is no other treatment. B) Aldesleukin C) Tumor necrosis factor inhibitors D) Colony-stimulating factor
Ans: B Feedback: Aldesleukin is a genetically engineered from of human interleukin-2. It is being used as biologic therapy for clients who have not responded to conventional cancer treatments to stimulate the immune system's ability to target cancer cells. Tumor necrosis factor inhibitors were originally going to be used for shrinking tumors but were found ineffective. Colony-stimulating factors help with manufacturing blood cells.
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery? A) Activation of the complement system B) Stimulation of colony-stimulating factors C) A cell-mediated response D) Naturally acquired active immunity
Ans: C Feedback: A cell-mediated response occurs when T cells survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading
A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have? A) The nurse ensures a written consent is obtained prior to testing. B) The nurse should send the client to have the blood drawn without informing him about the specific screening test. C) The nurse will call the client with the results of the test. D) The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC).
Ans: A Feedback: The nurse ensures that a written consent is obtained before testing for human immunodeficiency virus (HIV) and keeps the results of HIV testing confidential. The client should never be tested without his knowledge. The physician will review the results when the client comes in for a follow-up visit. It is not necessary for the nurse to report results to the CDC.
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications? A) Administer the medications that the physician ordered. B) Call the pharmacy and let them know the client has several drug allergies. C) Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. D) Give the client one medicine at a time and observe for allergic reactions.
Ans: C Feedback: Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy but still maintains responsibility for the medications administered.
A client will be starting treatment with the tumor necrosis factor inhibitor, adalimumab (Humira). To begin a new job, the client must receive a tetanus shot because he hasn't received one in 10 years. What should the nurse advise the client? A) The tetanus shot may be taken at any time without regard to TNF inhibitor drug therapy. B) The client should receive the tetanus shot prior to beginning TNF inhibitor drug therapy. C) The client should receive the tetanus shot after beginning TNF inhibitor drug therapy to decrease the complications related to the tetanus. D) The client should get a note from the physician stating the tetanus shot is not able to be taken by the client.
Ans: B Feedback: TNF inhibitors decrease the efficacy of vaccines that are T-cell dependent such as those for hepatitis B, viral influenza A and B, human papillomavirus, and tetanus. It is best for clients to receive these types of vaccines before beginning TNF inhibitor drug therapy. Options A, C, and D would be incorrect instructions to give the client.
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? A) Etanercept (Enbrel) B) infliximab (Remicade) C) Epoetin alfa (Epogen) D) Adalimumab (Humira)
Ans: C Feedback: 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 15-year-old client has been brought to the clinic by his mother and is suspected of having an immune system disorder. What tests would you expect to be ordered for this young client? A) Cerebral spinal fluids aspiration B) Sedimentary rate C) Complete blood count with differential D) Complete chemistry panel
Ans: C Feedback: Laboratory tests are used to identify immune system disorders. They usually include a complete blood count with differential. Protein electrophoresis screens for diseases associated with a deficiency or excess of immunoglobulins. T-cell and B-cell assays (or counts) and the enzyme-linked immunosorbent assay may be performed. Options A, B, and D are not diagnostic of immune disorders.
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? A) "They really do not have a function and should be removed." B) "These tissues filter bacteria from tissue fluid." C) "The tissue acts as an emergency reservoir of blood." D) "The tissue removes blood and bacteria."
Ans: B Feedback: 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.
What type of cytokine will attract neutrophils and monocytes to remove debris? A) Lymphokines B) Cytotoxic T cells C) Suppressor T cells D) Regulator T cells
Ans: A Feedback: Lymphokines, a type of cytokine, attract cells when they detect antigens and direct B-cell lymphocytes to multiply and mature. Cytotoxic T cells bind to invading cells, destroy the targeted invader by altering their cellular membrane and intracellular environment, and stimulate the release of chemicals called lymphokines. Suppressor T cells limit or turn off the immune response in the absence of continued antigenic stimulation. Regulator T cells are made of up of helper and suppressor cells.
A 64-year-old male client, who leads a sedentary lifestyle, and a 31-year-old female client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. As the nurse, you would know that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why? A) The male client because of his age B) The male client because of his lifestyle C) The female client because of her age D) The female client because of her lifestyle
Ans: A Feedback: Vaccines are less effective in an older adult than in a younger adult because the activity of the immune system declines with the aging process. The lifestyle or gender of the client does not have great implications on the effectiveness of a vaccine.
A client is cutting vegetable for dinner and accidently cuts his finger. What response is desirable to destroy foreign agents such as microorganisms to prevent infection from developing in the finger? A) A cell-mediated response B) The release of antibodies C) The release of memory cells D) Passive immunity
Ans: B Feedback: Antibodies are chemical substances that destroy foreign agents such as microorganisms, which decrease the risk of infection at the site. A cell-mediated response occurs when T cells 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 such as an organ transplant. Memory cells convert to plasma cells on reexposure to a specific antigen. When activated, B cells accumulate in lymphoid tissues and result in swollen lymph nodes. Passive immunity develops when ready-made antibodies are given to a susceptible person. They provide immediate but short- lived protection from an invading antigen.
A client's immune system has the ability to protect itself from external invaders. What type of immune function is present when this occurs? A) Immunosuppression B) Immunocompetence C) An immune response D) Immune incompatibility
Ans: B Feedback: The immune system is a collection of specialized white blood cells and lymphoid tissues that maintain immunocompetence, the ability to cooperatively protect a person from external invaders and the body's own altered cells. Immunosuppression is the opposite and the white blood cells and lymphoid tissue are not able to protect a person from external invaders. An immune response, primarily involves the lymphocytes that are located in blood and lymphoid tissue. Immune incompatibility is not relevant in this situation.
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? A) To find out if the client will be compliant with therapeutic treatments B) To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS) C) To determine if the client needs a referral to counseling services D) To determine what type of personality the client has
Ans: B Feedback: 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.
When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this? A) Artificially acquired active immunity B) Passive immunity C) Natural immunity D) Naturally acquired active immunity
Ans: A Feedback: Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated toxin). The memory cells manufactured by the B lymphocytes "remember" the killed or weakened antigen and recognize it if a future invasion occurs. Passive immunity develops when ready-made antibodies are given to a susceptible person. Natural immunity is not one of the types of immunity. Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism.
A client asks the nurse about the importance of taking supplements to maximize immune function. The client is healthy and does not have any medical problems. What is the best information to give to the client? A) Instead of taking supplements, eat a lot of fruits and vegetables, and this will help maximize immune function B) Adopt a vegetarian diet and omit all meats, and you will maximize immune function. C) You should take a variety of vitamin and mineral supplements to maximize immune function. D) Eating a moderate diet that is balanced and varied will maximize immune function.
Ans: D Feedback: Until more is known about nutrient interactions, the best dietary advice to maximize immune function in healthy people is to eat a moderate diet that is balanced and varied. Eating fruits and vegetables and a vegetarian lifestyle may be healthy choices but do not maximize immune function as a balanced diet will. Because little is known about nutrient interactions, dietary balance is optimum.
You are caring for a client on tube feedings. The physician has ordered Osmolite HN as the feeding formula for the client. The family asks why the physician has ordered Osmolite HN instead of another formula to feed their family member. What is an important reason that tube-feeding formulas, such as Impact, Osmolite HN, or Perative, be recommended to clients? A) To suppress immune system function B) To block tumor necrosis factor C) To enhance the production of lymphocytes and NK cells D) To stimulate the immune system to attack tumor cells
Ans: C Feedback: Immune-enhancing tube-feeding formulas enhance the production of lymphocytes and NK cells, resulting in increased cell-mediated immunity. Drugs such as azathioprine, cyclosporine, and muromonab-CD3 suppress immune system function, whereas infliximab and etanercept minimize inflammation by blocking tumor necrosis factor. Aldesleukin is used as biologic therapy for clients who do not respond to conventional cancer treatment. Aldesleukin stimulates the immune system's ability to attack tumor cells.
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have? A) Naturally acquired active immunity B) Artificially acquired active immunity C) Passive immunity transferred by the mother D) There is no immunity passed down from mother to child.
Ans: C Feedback: 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. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid.
.The anatomy and physiology instructor is explaining a cell-mediated response to the prenursing students. What actions would the instructor explain occur in a cell-mediated response? A) Toxins of invading antigens are neutralized. B) The invading antigens link together (agglutination). C) The invading antigens precipitate. D) T-cell lymphocytes survey proteins in the body and attack the invading antigens.
Ans: D Feedback: 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.