Chapter 31: Assessment of Immune Function

During a 12-month well-baby visit, a mother reports that the baby has been breastfed since birth and has never been ill. The mother is trying to convince her sister, who is currently pregnant, to breastfeed also and asks the nurse about the benefits of breastfeeding. The nurse explains the immune benefits of breastfeeding and provides the mother with pamphlets. The nurse determines the mother understands the teaching based on which statement?

"Breastfeeding is beneficial because the dominant antibody IgA in breast milk acts by functioning as an antigen receptor in the mucosal membranes."

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?

"It is a hyperimmune response to something in the environment that is usually harmless."

A client with an autoimmune disorder asks, "Why is autoimmune disease more prevalent in the women in my family?" Which response will the nurse make to this client?

"It's believed to be caused by the differences in the sex hormones."

A client is informed of having a low white blood cell count and that the client 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."

The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?

A 65-year-old client who had chicken pox when he was 12 years old

A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?

Administer epinephrine.

Which of the following is the most severe form of hypersensitivity reaction?

Anaphylaxis

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

A client developed an infection while on vacation in Central America and is now taking the antibiotic chloramphenicol. What should the client be monitored for when taking this drug?

Aplastic anemia

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

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?

Ataxia

Which of the following cell types are involved in humoral immunity?

B lymphocytes

A patient is being treated in the intensive care unit for sepsis related to ventilator-associated pneumonia. The patient is on large doses of three different antibiotics. What severe outcome should the nurse monitor for in the lab studies?

Bone marrow suppression

A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse of having 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?

Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.

The nurse is obtaining the medical history of a client with Crohn's disease. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?

Corticosteroids

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

Cytotoxic T cell

All the following items are related to cancer. Which does not affect the immune system?

Diagnostic tests for cancer

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

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 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)

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

Exposure to foreign antigens may cause altered immune function.

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

Humoral

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?

IgE

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses?

Immunosenescence

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?

Lymphocyte

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 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

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 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

A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles?

Phagocytosis

The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function?

Previous organ transplantation

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

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

Renal function decreases

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

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.

The nurse is beginning the physical examination of a client with fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?

The client appears mildly ill, listless, and disheveled.

A 64-year-old male client, who leads a sedentary life-style, and a 31-year-old female client, who has a very stressful and active life-style, 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?

The male client because of his age

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?

The nurse ensures a written consent is obtained prior to testing.

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

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

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen.

Immunocompetence is the ability of the immune system to cooperatively protect a person from external invaders and the body's own altered cells. Immunocompetence is maintained by white blood cells and:

lymphoid tissue.

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

naturally acquired active immunity

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

neutrophils and monocytes.

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."

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

Natural immunity

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

Naturally acquired active immunity

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."

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.

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated?

Cytotoxic T cells

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 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.

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

What organ is considered lymphoid tissue?

Spleen

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.

Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that:

filter bacteria from tissue fluid.

In which response do T lymphocytes have a role?

transplant rejection

During an annual examination, an older client tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel just fine!" Based on knowledge of neoplastic disease and the aging immune system, what teaching should the nurse include in the client's plan of care? Select all that apply.

Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes; therefore the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early. The increase in occurrence of autoimmune diseases with aging strongly suggests a predisposition toward various types of cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of finding and treating cancer early. Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development.

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.

The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?

interferons

The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger promotes inflammation, fever, and angiogenesis?

interleukins