Med Surg: Chapter 35

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 plasma." "White blood cells are produced in the bone marrow." "White blood cells are produced in the lymphatic tissue." "White blood cells are produced in the thymus gland."

"White blood cells are produced in the bone marrow. "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 is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine? A 17-year-old client who will be attending college and living in a dormitory A 65-year-old client who had chicken pox when he was 12 years old A 32-year-old client who has never had chickenpox A 24-year-old client who is pregnant

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

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? Stimulation of colony-stimulating factors Naturally acquired active immunity A cell-mediated response Activation of the complement system

A cell-mediated responseExplanation: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. An example of a cell-mediated response is one that occurs when an organ is transplanted. The 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. Colony-stimulating factors prompt the bone marrow to produce, mature, and promote the functions of blood cells. Naturally acquired active immunity is a direct result of infection by a specific microorganism. pg.971)

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? Perform an electrocardiogram (ECG). Administer epinephrine. Intubate the client. Assess the client's vital signs.

Administer epinephrine.

Which of the following is a medical condition that is an example of a humoral immune response? Fungal infection Parasitic infection Asthma Transplant rejection

Asthma

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system? Burning upon urination Hematuria Urinary frequency Ataxia

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

Which of the following cell types are involved in humoral immunity? Helper T lymphocyte Suppressor T lymphocyte Memory T lymphocyte B lymphocytes

B lymphocytes

Which condition is associated with impaired immunity relating to the aging client? Increase in peripheral circulation Increase in humoral immunity Decrease in inflammatory cytokines Breakdown and thinning of the skin

Breakdown and thinning of the skin pg. 978

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? Call the pharmacy and let them know the client has several drug allergies. Give the client one medicine at a time and observe for allergic reactions. Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. Administer the medications that the physician ordered.

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

Which of the following is a age-related change associated with the immune system? Decreased antibody production Increased antibody production Elevated phagocytic immune response Ability to differentiate "self" from "nonself"

Decreased antibody production

Which of the following protective responses begin with the B lymphocytes? Cellular Recognition Phagocytic Humoral

Humoral

Which of the following is a center for immune cell proliferation? Liver Spleen Lymph node Pancreas

Lymph node The lymph nodes remove foreign material from the lymph system before it enters the bloodstream. They are centers for immune cell proliferation.

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: B-lymphocytes respond to a specific antigen Antibodies are released into the bloodstream Lymphocytes migrate to areas of the lymph node Antibodies reside in the plasma

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? Cytokines Lymphoid tissues Red blood cells Stem cells

Lymphoid tissues

What chemical is released by cytotoxic T cells? Lymphokine Microphages Antigen Antibody

Lymphokine

Which type of immunity becomes active as a result of infection by a specific microorganism? Artificially acquired active immunity Naturally acquired active immunity Artificially acquired passive immunity Naturally acquired passive immunity

Naturally acquired active immunity

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include: lymphokines and suppressor T cells. regulator T cells and helper T cells. neutrophils and monocytes. plasma cells and memory cells.

Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.

What is the function of the thymus gland? Produce stem cells Programs B lymphocytes to become regulator or effector B cells. Develop the lymphatic system Programs T lymphocytes to become regulator or effector T cells.

Programs T lymphocytes to become regulator or effector T cells.

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 causes an excess of circulating hemoglobin. Radiation causes a deficiency of circulating hemoglobin. Radiation causes an excess of circulating lymphocytes. Radiation destroys lymphocytes.

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? Plasma, which depletes the body's store of catecholamines Serum, which depletes the body's store of immunoglobulins Plasma, which depletes the body's store of calcitonin Serum, which depletes the body's store of glucagon

Serum, which depletes the body's store of immunoglobins

A nurse is teaching a community group about healthy lifestyles. A participant asks about how to maintain a healthy immune system. The nurse informs the group that which factor will positively affect the immune system? Poor nutritional status Residential exposure to radiation Strong family and community connections Rigorous, competitive exercise

Strong family and community connections

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. T-cell and B-cell lymphocytes respond to the body's invasion by macrophages. T-cell and B-cell lymphocytes react to the body's lack of B12 . T-cell and B-cell lymphocytes distinguish harmful treatments from curative treatments.

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

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? Regulatory mechanisms fail to halt the immune response. Excess cytokines cause tissue damage. The immune system recognizes one's own tissues as "foreign." The immune system recognizes one's own tissues as "self."

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. The client will have a productive cough. The injection area will become painful with in duration if the client has antibodies against the antigen. The injection area will break out in a fine macular rash.

The injection area swells if the client has developed antibodies against the antigen. pg. 588

The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which statement correctly describes the process of autoimmunity? The body overproduces immunoglobulins. The normal protective immune response attacks the body, damaging tissues. The body produces inappropriate or exaggerated responses to specific antigens. A deficiency results from improper development of immune cells or tissues.

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

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. eliminate cancer cells. increase the efficacy of antibiotics. program T lymphocytes

They are lymphoid tissues that filter bacteria from tissue fluid.

A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this client for which reason? Excess circulating hemoglobin Excess circulating lymphocytes Deficient circulating antibodies Use of anti-rejection drugs

Use of anti-rejection drugs

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 harmless reaction to something in the environment." "It is a muted response to something in the environment." "It is a hyperimmune response to something in the environment that is usually harmless." "It means you are very sensitive to something inside of yourself."

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

An older client doesn't understand why advancing age increases susceptibility to illness. What will be included in the nurse's explanation? Select all that apply. The amount of antibody produced in response to most foreign antigens decreases with age. The body's number of B-cell lymphocytes decreases with age. The body's lymphoid tissue decreases with age. The body's number of T-cell lymphocytes decreases with age.

The amount of antibody produced in response to most foreign antigens decreases with age. The body's number of T-cell lymphocytes decreases with age.

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? Hypoprothrombinemia Eosinophilia Neutropenia Aplastic anemia

aplastic anemia

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? B cells Helper T cells Macrophages Cytotoxic T cells

Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and by releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other lymphocytes and white blood cells. These cells then assist in destroying the invading organism.

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? Blood products cause lower antibody titers. Exposure to foreign antigens may cause altered immune function. Blood products cause a high risk for exposure to HIV. Blood products cause a high risk for hepatitis B.

Exposure to foreign antigens may cause altered immune function.

An elderly client is diagnosed with a respiratory infection. While reviewing age-related changes in the immune system, what would the nurse identify as having contributed to this client's infection? Impaired ciliary action from exposure to environmental toxins Decreased sensation and slowing of reflexes Failure of the immune system to differentiate "self" from "non-self" Decreased phagocytosis by Kupffer cells

Impaired ciliary action from exposure to environmental toxins

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. The nurse will call the client with the results of the test. The nurse should send the client to have the blood drawn without informing him about the specific screening test. The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC).

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

Which statement accurately reflects current stem cell research? Clinical trials are underway only in clients with acquired immune deficiencies. Stem cell transplantation cannot restore immune system functioning. The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Stem cell transplantation has been performed in the laboratory only.

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

A 38-year-old client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. Which is the most important factor related to the client's assessment? Diet Use of other drugs Age Home environment

Use of other drugs

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? Nonsteroidal anti-inflammatory Diuretics Corticosteroids Angiotensin-converting enzyme inhibitors (ACE-I)

Corticosteroids

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? Passive immunity Naturally acquired active immunity Artificially acquired active immunity Natural passive immunity

Naturally acquired active immunity

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? Assist the client with scheduling the procedures Encourage the client to ask the physician for information about treatment options for the possible diagnosis Educate the client about the diagnostic procedures and answer their questions about the possible diagnosis Accompany the client to the diagnostic tests

Educating the patient about the diagnostic procedures and answer questions they may have about the possible diagnosis

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 Neutrophil Basophil Monocyte

LymphocyteExplanation: The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes ... (more) The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

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: acidosis because the spleen maintains acid-base balance. infection because the spleen removes bacteria from the blood. bleeding because the spleen synthesizes vitamin K. anemia because the spleen produces red blood cells.

infection because the spleen removes bacteria from the blood.