Ch. 35 Immune Function

A client has been diagnosed with AIDS. Which of the following statements correctly describes a secondary immune deficiency?

An interference develops in an already developed immune system A secondary immune deficiency results from some interference with an already developed immune system. A primary deficiency results from improper development of immune cells or tissues. A hypersensitivity happens when the body produces an inappropriate or exaggerated response to a specific antigen. Autoimmunity happens when the normal protective immune response pradoxically turns against or attacks the body, leading to tissue damage. It is not an immune deficiency.

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?

Corticosteroids

Which of the following occurs when the antigen-antibody molecule is coated with a sticky substance what also facilitates phagocytosis?

Opsonization In this process, the antigen-antibody molecule is coated with a sticky substance that also facilitates phagocytosis. One antibody can act as a cross-link between two antigens, causing them to bind or clump together. This clumping effect, referred to as agglutination, helps clear the body of the pathogen by facilitating phagocytosis. The portion of the antigen involved in binding with the antibody is referred to as the antigenic determinant. Circulating plasma proteins, known as complement, are made in the liver and other sites and activated when an antibody connects with its antigen.

A - IgA

interferes with the entry of pathogens through exposed structures or pathways. 15% total immunoglobulin. Found in body fluids. Passes to neonate via breastmilk (RESPIRATORY, GASTROINTESTINAL, GENITOURINARY)

The nurse is caring for an older adult patient hospitalized with cellulitis of the right lower extremity. Why is it imperative that the nurse continually assess the physical and emotional status of this patient?

pt develop depression and suicidal tendencies when faces with chronic illness. The effects of the aging process and psychological stress interact, with the potential to negatively influence immune integrity (Masoro & Austad, 2011). Consequently, continual assessment of the physical and emotional status of older adults is imperative, because early recognition and management of factors influencing immune response may prevent or mitigate the high morbidity and mortality seen with illness in the older adult population (Brunner et al., 2011; Swain & Nikolich-Zugich, 2009).

Immune Response Stages ProRecResEff Response stage -

the changed lymphocytes function either in a humoral or cellular fashion. (LET US FIX THE FISHY, WHAT DO WE NEED?)

Cell mediated response (T cells)

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. An example of a cell-mediated response is one that occurs when an organ is transplanted.

A client with lupus erythematosus wants to know why autoimmune disorders are much more common in women. The nurse correctly responds with which of the following statements?

"Estrogen tends to enhance immunity."

The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed?

"I can take my child to the beach, as long as we play in the sand rather than swim in the water."

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)

When a nurse infuses gamma globulin intravenously, the rate should not exceed

3mL/minute

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 cell-mediated response

Which of the following is a medical condition that is an example of a humoral immune response?

Asthma

Complement system

Complement refers to a series of enzymatic proteins in the serum that, when activated, destroy bacteria and other cells.

Complement system

cooperates with antibodies to attract phagocytes and coat antigens to make them more recognizable for phagocytosis and stimulate inflammation and is not related to the surgery.

A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which statement?

"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling."

There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency.

"Your immune system was most likely affected by an underlying disease process."

The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following?

Serum, which depletes the body's store of immunoglobulins Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. Loss of serum or plasma does not deplete the body of catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas).

Antibodies

Antibodies = protein substances developed by the body in response to and that interact with a specific foreign substance. (TARGET; COMBAT ALIEN SUBSTANCE)

Antigens

Antigens = substances that induce formation of antibodies. (TARGET STIMULUS; THE ALIEN SUBSTANCE)

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed?

"I will be sure to eat lots of fresh fruits and vegetables every day."

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."

Which response is a humoral immune response?

Anaphylaxis

A nurse is monitoring a client who developed facial edema after receiving a medication. Which white blood cells stimulated the edema?

Basophils

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.

Cytotoxic T cell

A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which of the following reasons?

Exposure to foreign antigens may cause altered immune function.

Which immunoglobulin assumes a major role in bloodborne and tissue infections?

IgG

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?

Lymphoid tissues

What chemical is released by cytotoxic T cells?

Lymphokine

A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?

Natural immunity

A client has a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?

Protein electrophoresis

An older adult patient who is postmenopausal informs the nurse that she believes she has developed another urinary tract infection (UTI). The nurse understands that postmenopausal females are at greater risk for UTIs. What risk factors do female patients in this age group have? (Select all that apply.)

Residual urine Urinary incontinence Estrogen deficiency

Which adverse effect should the nurse closely monitor in a client who takes immunosuppressive drugs?

Respiratory or urinary system infections

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 (you can never have too much of a good thing) Although factors that are not consistent with a healthy lifestyle are predominantly 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).

What organ is considered lymphoid tissue?

Spleen

Which messenger enables cells to resist viral replication and slow viral replication?

interferons

Artificially acquired immunity is obtained by

receiving a killed or weakened microorganism or toxoid. (Vaccines)

The nurse caring for a client with renal failure is most concerned about a compromised immune system in the client for which of the following reasons?

A deficiency of circulating lymphocytes

A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?

Assure the client that this is a normal reaction

General role of: Basophil Eosinophil Neutrophil/Monocytes NK cells (Natural Killer)

Basophils = HISTAMINE Eosinophil = COMPLEX PHAGO (helminth) Monocytes/Neutrophil = GENERAL PHAGO NK cells = free-floating policemen cells looking for infected/cancerous cells

Activation of a natural immunity response is enhanced by physical and chemical barriers. Which of the following is a physical barrier, which the nurse knows can be altered by illness, nutrition, or lifestyle?

Cilia of the respiratory tract

A nurse is caring for a client undergoing evaluation for possible immune system disorders. Which intervention will best help support the client throughout the diagnostic process?

Educate the client about the diagnostic procedures and answer their questions about the possible diagnosis

What function are helper T-cells important in?

Fighting infection

A mother has brought her child to the clinic for a wellness check. While talking with the nurse, the mother asks the nurse to suggest a diet that will maximize the immune function of her growing children. What dietary pattern should the nurse suggest?

Moderate diet that is balanced and varied

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Natural killer cells

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?

Naturally acquired active immunity

Which type of immunity becomes active as a result of infection by a specific microorganism?

Naturally acquired active immunity

A majority of clients with CVID develop which type of anemia?

Pernicious

Which condition is associated with impaired immunity relating to the aging client?

Renal function decreases

Which statement accurately reflects current stem cell research?

The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

Naturally Acquired Active Immunity

immunity is a direct result of infection by a specific microorganism.

D - IgD

possibly influences B-Lymphocyte differenciation

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?

"White blood cells are produced in the bone marrow."

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

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. Which of the following would the nurse expect to be started?

Immunosuppressive agents

What does the nurse understand will result if the patient has a deficiency in the normal level of complement?

Increased susceptibility to infection

A 34-year-old client is diagnosed with chronic hepatitis C. Testing reveals that the client is a candidate for treatment. The nurse anticipates that which therapy could be used to treat the client's condition?

Interferon Interferons are used to treat immune-related disorders (e.g., multiple sclerosis) and chronic inflammatory conditions (e.g., chronic hepatitis).

Interferons

Interferons = proteins formed when cells are exposed to viral or foreign agents that are capable of activating other components of the immune system (THEY /INTERFERE/ WITH RESPONSES)

When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?

Lymphocyte

Which of the following conditions would place the client at risk for impaired immune function?

Previous organ transplantation

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?

Surgical removal of the appendix

What are the primary participants in the immune system?

T- and B- cell lymphocytes

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?

The injection area swells if the client has developed antibodies against the antigen.

The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which of the following statements correctly describes the process of autoimmunity?

The normal protective immune response attacks the body, damaging tissues.

To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen.

The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. A clinical manifestation is telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what?

Vascular lesions caused by dilated blood vessels

M - IgM

agglutinates antigens and lyses cell walls. (FIRST RESPONDER)

Colony-stimulating factors

prompt the bone marrow to produce, mature, and promote the functions of blood cells.

While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. Which of the following would have a positive effect on the immune system?

Biofeedback, relaxation, and hypnosis

The nurse is preparing a teaching plan for a client with an immunodeficiency. Which of the following would the nurse emphasize as most important?

Frequent and thorough handwashing

Which of the following protective responses begin with the B lymphocytes?

Humoral

A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen?

IV gamma globulin administration

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is

Malnutrition

Immune Response Stages ProRecResEff Proliferation phase

circulating lymphocytes containing the antigenic message return to the nearest lymph node. Once in the node, the sensitized lymphocytes stimulate some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. (HEY, SOMETHING IS FISHY, LETS GO CHECK IT OUT)

A client is diagnosed with severe combined immunodficiency (SCID). Which of the following would the nurse expect to integrate into the client's plan of care?

Preparation for bone marrow transplantation

T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?

T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.

A nurse is explaining treatment options to a client diagnosed with an immune dysfunction. Which statement by the client accurately reflects the teaching about current stem cell research?

"Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, and clinical trials using stem cells are underway in clients with a variety of disorders with an autoimmune component."

A nurse is working in a pediatric clinic. After giving a hepatitis B immunization to an infant, the mother asks what kind of protection this provides for her child. The correct response is which of the following?

Active acquired immunity, which lasts many years or a lifetime

A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected?

Assess for ataxia using the finger-to-nose test and heel-to-shin test

What type of immunoglobulin does the nurse recognize that promotes the release of vasoa ctive chemicals such as histamine when a client is having an allergic reaction?

IgE

Based on knowledge of the immune system, the delivery room nurse explains about which immunoglobulin that will be increased in the fetus at the time of birth and will be actively fighting the infection?

IgG

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:

Lymphocytes migrate to areas of the lymph node

The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents?

Macrophages

A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand?

Neutrophils

A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity?

Potato chips and chocolate milk shakes keyword is stimulating autoimmunity, so we're looking for unhealthy stuffs.

A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately?

Tickle in the throat

Immune Response Stages ProRecResEff Effector stage -

either the antibody of the humoral response or the cytotoxic T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader. (ANTIBODIES NOW TAKING CARE OF THE FISH)

Immune Response Stages ProRecResEff Recognition stage -

the immune system distinguishes an invader as foreign, or non-self. (YOU'RE RIGHT IT WAS FISHY OR NO IT WAS OK)

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?

Passive immunity transferred by the mother Passive immunity develops when ready-made antibodies are given to a susceptible person. (Mom's breastmilk)

A client has breast cancer. The nurse is concerned about a compromised immune system in this client for which of the following reasons?

Antineoplastic drug therapy Antineoplastic drugs cause a compromised immune system. Breast cancer is not associated with an excess of lymphocytes, a deficiency of circulating antibodies, or an excess of hemoglobin.

The nurse's base knowledge of primary immunodeficiencies includes which of the following statements?

Primary immunodeficiencies develop early in life after protection from maternal antibodies decreases.

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

While taking the health history of a newly admitted client, the nurse asks for a list of the client's current medications. Which of the following medication classifications would place the client at risk for impaired immune function?

Antimetabolites Antimetabolites can cause leukopenia, eosinoplilia, aplastic bone marrow, and pancytopenia. The other choices do not directly affect the immune system.

Naturally acquired active immunity occurs as a direct result of

infection by a specific microorganism. (measle immunity after getting measles)

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?

Bone marrow transplantation

A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this client for which of the following reasons?

Use of anti-rejection drugs These drugs cause a compromised immune system. Renal transplant is not associated with excess lymphocytes, deficient circulating antibodies, or excess hemoglobin.

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?

Autoimmune disorders include connective tissue (collagen) disorders.

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:

neutrophils and monocytes.

The majority of patient with primary immunodeficiency are in which age group?

Younger than 20

E - IgE

promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reaction.

A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to:

infection because the spleen removes bacteria from the blood.

G - IgG

neutralizes bacterial toxins and accelerates phagocytosis. 75% of total immunoglobulin. Crosses placenta. (BLOODBORNE, TISSUE INFECTIONS)