Chapter 18 and 19 Adult Health

A patient asks the nurse how an allergy can develope to a medication that has been taken before without problems. Which of the following is the most appropriate response? "It probably is due to your age, because as we age, the body becomes more sensitive to environmental stimuli, which leads to hypersensitives." " What have you eaten in the last 24 hours? Most medications are altered by food, thereby producing different effects in the body." " Viral illnesses and exposure to various chemicals and enviornmental substances can alter the immune system and its response to previously benign stimuli." " Patients who have autoimmune disorders such as lupus or arthritis tend to develop sensitivities to common medications."

" Viral illnesses and exposure to various chemicals and enviornmental substances can alter the immune system and its response to previously benign stimuli."

The nurse is caring for a patient who asks what ankylosing spondylitis is. Which of the following responses from the nurse is appropriate? "It is a chronic progressive inflammatory disease of the spine and large limb joints." "Autoantibodies lyse (undergo) red blood cells." "There is a formation of antigen-antibody complexes leading to inflimmation." "Production of immunoglobulin E antibodies occurs."

"It is a chronic progressive inflammatory disease of the spine and large limb joints."

The client with diagnosed acquired immunodeficiency syndrome (AIDS) AND Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101°F (38.8°C). The nurse continues to monitor the client , knowing that this sign would most likely indicate which condition? The dose of the medication is to low. The client is experiencing toxic effects of the medication. The client has developed inadequacy of thermoregulation. A result of another infection caused by the leukopenic effects of the medication.

A result of another infection caused by the leukopenic effects of the medication.

Angioedema

A result of vascular permeability that increases in the submucousal and subcutaneous layers

Histamine

A substance produced in the body that increases gastric secretion, capillary permeability, and contracts the bronchial smooth muscle. Plays a role in allergic reaction.

What is anaphylactic?

A sudden severe allergic reaction to an allergen.

What is active immunity?

Acquired immunity attributable to the presence of antibodies or of immune lymphnoid cells formed in response to antigenic stimulus.

What is another name for Humoral immunity? Answer: Antibody mediated immunity What are the three different types of lymphocytes? Natural Killer cells T cells B cells All of the Above

All of the above

What is cell mediated immunity effective against? intracellular pathogens Malignant cells Foreign tissue grafts All of the Above

All of the above

The nurse is caring for a patient who is suspected to be infected with HIV. The patient asks what type of test will be done first to diagnose it. Which response by the nurse would be appropriate? Antibody differentiation immunoassay Antigen/ antibody combination immunoassay Lymphocyte count Nucleic acid test

Antigen/ antibody combination immunoassay

What is a antigen?

Antigens are chemical markers that identify cells or molecules.

The nurse is caring for a patient with allergic rhinitis. Which of the following interventions should the nurse anticipate will be included in the treatment plan for this patient? Select all that apply. Antihistamines Anticholinergics Avoiding Enviornmental stimuli Decongestants Immunotherapy Steroids

Antihistamines Avoiding Enviornmental stimuli Decongestants Immunotherapy Steroids

The nurse teaches a patient about vaccines. The nurse would evaluate the patient as understanding the presented information if the patient states that a vaccine provides which of the following types of immunity? Naturally acquired passive immunity Artificially acquired passive immunity Naturally acquired active immunity Artificially acquired active immunity

Artificially acquired active immunity

Saquinavir is prescribed for the client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse would reinforce medication instructions about which health care measure to the client? Avoid sun exposure Eat low calorie foods Eat foods that are low in fat Take the medication on an empty stomach

Avoid sun exposure

The nurse is collecting data on a patient with suspected pernicious anemia. Which of these signs or symptoms would the nurse expect to find for this patient? Select all that apply. Back spasms Glossitis Itching Kyphosis Pallor Weakness

Glossitis Pallor Weakness

What is a antibody?

Glycoprotiens produced by plasma cells in response to foreign antigens.

Amikacian is prescribed for a client with a diagnosied bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs? Nausea Lethargy Hearing loss Muscle aches

Hearing loss

A patient has a increased antibody level which is increased during exercise and obstructive jaundice. Which antibody is being affected? IgG IgM IgA IgE IgD

IgA

A patient is showing a decrease in agammaglobulinemia. Which antibody is being affected? IgG IgM IgA IgE IgD

IgD

A patients antibody level is increased in allergic reactions and allergic infections. Which antibody is being affected? IgG IgM IgA IgE IgD

IgE

A patient has a increased antibody level causing a increased risk of infection, liver disease, rheumatoid arthritis, and dermatological disorders. Which antibody is being affected?

IgG

A patient has a increased antibody level in Malaria, infectious mononucleosis, SLE, and rheumatoid arthritis. Which antibody is being affected?

IgM

Ankylosing spondylitis

Inflammatory disease of the spine causing stiffness and pain

Which of the following vaccines would the nurse correctly recommend be given annually during a teaching session on health maintenance with an older patient? Diptheria tetanus Influenza Pneymococcal vaccine Polio

Influenza

Ketoconazole is prescribed for a client with diagnosis of candidiasis. Which interventions would the nurse include when administering this medication? Select all that apply. Restrict fluid intake Monitor live function studies Instruct the client to avoid alcohol Administer the medication with an antacid Instruct the client to avoid exposure to the sun Administer the medication on an empty stomach

Monitor live function studies Instruct the client to avoid alcohol Instruct the client to avoid exposure to the sun

The nurse is reviewing the results of the serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted? Serum protein Blood glucose Serum amylase Serum creatinine

Serum amylase

The nurse is assigned to care for the client diagnosed with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet. The nurse would monitor the results of which laboratory study while the client is taking this medication? CD4+ cell count Lymphocyte count Serum albumin level Serum creatinine level

Serum creatinine level

The nurse is assisting with data collection on a patient. Which of the following past surgeries found in the patient's histoy would alert the nurse to possible immune system dysfunction when planning care? Appendectomy Parathyroidectomy Pneumonectomy Splenectomy Thyroidectomy Thymectomy

Splenectomy Thymectomy

A patient is receiving cerfuroxime (Zinacef) intravenously, Fifteen minutes after the cefuroxime is started, the patient reports an uneasy feeling as well as feeling very warm. Which actions would the nurse take now? Select all that apply. Offer the patient ice water. Discontinue the angiocath. Stay with the patient. Turn off the intravenous infusion. Call for assistance. Monitor vital signs.

Stay with the patient. Turn off the intravenous infusion. Call for assistance. Monitor vital signs.

Urticaria (hives)

a type 1 hypertensitivity reaction

A camp nurse prepares to instruct a group of children about Lyme disease. Which information would the nurse include in the instructions? a) Lyme disease is caused by a tick carried by deer. b) Lyme disease is caused by contamination from cat feces. c) Lyme disease can be contagious by skin contact with an infected individual d) Lyme disease can be caused by the inhalation of spores from bird droppings

a) Lyme disease is caused by a tick carried by deer

A baby is born temporarily immune to the disease to which the mother is immune. The nurse would explain to which the mother is immune. The nurse would explain this to the mother as being which of the following types of immunity? a) Naturally acquired passive immunity b) Artificially acquired passive immunity c) Naturally acquired active immunity d) Artificially acquired active immunity

a) Naturally acquired passive immunity

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse would monitor for which side/adverse effects of the medication? Select all that apply. a) Rash b) Hepatotoxicity c) Hyperglycemia d) Peripheral neuropathy e) Reduced bone mineral density

a) Rash b) Hepatotoxicity

The nurse is teaching a pt about immune function. Which of the following would the nurse correctly include as stimulating antibody production? Select all that apply. a) Cold virus b) Plant pollen c) Transplanted organ d) Bacterial toxins e) Measles vaccine

a) cold virus b) plant pollen d) bacterial toxins e) measles vaccine

The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse would incorporate which intervention as a priority in the plan of care? a) Protecting the client from infection b) Providing emotional support to decrease fear c) Encouraging discussion about life style changes d) Identifying factors that decreased the immune function

a) protecting the client from infection

While collecting data the nurse suspects that a patient is experiencing an immune disorder. What data did the nurse use to come to this conclusion? Select all that apply. a. Rash b. Fever c. Joint pain d. Muscle cramps e. Swollen glands

a) rash b) fever c) joint pain e) swollen glands

Which interventions would be implemented in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. a) Use non-latex gloves. b) Use medications from glass ampules c) Place the client in a private room only. d) Do not puncture rubber stoppers with needles e) Keep a latex-safe supply cart available in the clients' area f) Use a blood pressure cuff from an electronic device only to measure the blood pressure.

a) use non-latex gloves b) use meds from glass ampules d) don't puncture rubber stoppers with needles e) keep a latex-safe supply cart available in the clients' area

While hospitalized it is discovered that a patient has an allergy to latex. What should this patient's discharge instructions include? (Select all that apply.) a) Wear a medical alert bracelet b) Carry an epinephrine auto-injector c) Restrict the intake of dairy products d) Restrict exercise to 30 mins each day e) Avoid consuming green leafy vegetables

a) wear a medical alert bracelet b) carry an epinephrine auto-injector

The activation of B cells in humoral immunity is assisted by which of the following? a) Cytotoxic T cells b) Helper T cells c) Suppressor T cells d) Neutrophils

b) Helper T cells

The nurse is caring for a patient who is experiencing an immune response involving B and T cells. Which type of immunity is the patient demonstrating? a) Passive immunity b) Humeral immunity c) Acquired immunity d) Cell-mediated immunity

b) Humeral immunity

The nurse is preparing an injection for an individual who requires passive immunity. In which situation would passive immunity be indicated? a) For permanent immunity against a disease b) To overcome an allergic reaction that is relatively mild c) To have ready-made antibodies after an exposure to pathogens d) As a booster dose to stimulate the production of specific antibodies

c) To have ready-made antibodies after an exposure to pathogens

The nurse is assisting with the administration of immunizations at a health care clinic. The nurse would understand that immunization provides which protection? a) Protection from all disease b) Innate immunity from disease c) Natural immunity from disease d) Acquired immunity from disease

d) Acquired immunity from disease

The client diagnosed with aquired immunodeficiency syndrome (AIDS) has begun therapy with zidovudine. The nurse would monitor which laboratory results during treatment with this medication? a) Blood culture b) Blood glucose level c) Blood urea nitrogen d) Complete blood count

d) Complete blood count