MedSurg 2 Final Exam Part 11
The nurse should recognize a patient's risk for impaired immune function if the patient has undergone surgical removal of which of the following? A) Thyroid gland B) Spleen C) Kidney D) Pancreas
B (Feedback:A history of surgical removal of the spleen, lymph nodes, or thymus may place the patient at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system.)
Which action prevents bacterial contamination during a blood transfusion? 1. Administering the blood within 4 hours of obtaining from blood bank 2. Making certain the blood product and patient's blood type match 3. Washing hands thoroughly before hanging the blood 4. Using medical asepsis when handling the blood
1. Administering the blood within 4 hours of obtaining from blood bank
Which is a type IV hypersensitivity reaction? 1. Allograft rejection 2. Allergic rhinitis 3. Wheal and flare 4. Atopic allergy
1. Allograft rejection
Which is a clinical example of a type II hypersensitivity reaction? 1. Blood transfusion reaction 2. Rash from poison ivy 3. Serum sickness 4. Hay fever
1. Blood transfusion reaction
Which manifestations are typical of type I systemic anaphylaxis? 1. Dyspnea, wheezing, laryngeal edema 2. Itching, hypertension, tachycardia 3. Labored breathing, rales, hives 4. Nausea, diaphoresis, chest pain
1. Dyspnea, wheezing, laryngeal edema
Which clinical manifestations are associated with circulatory overload in patients receiving blood? 1. Hypertension, chest tightness, jugular vein distention 2. Fever, abdominal cramping, increased urine output 3. Flushing, tachycardia, hypotension 4. Nausea, vomiting, low back pain
1. Hypertension, chest tightness, jugular vein distention
The patient at greatest risk for suppressed immunity is the patient who: 1. Is receiving chemotherapy for cancer 2. Is recovering from an appendectomy 3. Has been exposed to chickenpox 4. Has a history of allergies
1. Is receiving chemotherapy for cancer
Which is the appropriate therapy for serum sickness (type III hypersensitivity)? 1. Intravenous gamma globulins 2. Antihistamines and salicylates 3. Oral glucocorticosteroids 4. Epinephrine and steroids
2. Antihistamines and salicylates
Patients with contact dermatitis are taught to: 1. Use antibiotic creams 2. Avoid scratching the lesions 3. Coat their hands with lanolin 4. Soak their hands in mild detergent
2. Avoid scratching the lesions
Multiple myeloma is characterized by: 1. Hypokalemia and leukopenia 2. Hypercalcemia and hypouricemia 3. Hypocalcemia and hyperuricemia 4. Thrombocytopenia and hyperkalemia
2. Hypercalcemia and hypouricemia
Clinical manifestations commonly associated with chronic fatigue syndrome (CFS) include: 1. Chronic infections 2. Insomnia and sore throat 3. Rash and hyperexcitability 4. Dysrhythmias and hypertension
2. Insomnia and sore throat
Persons with B-cell deficiencies experience reduced: 1. Ability to stop the immune response 2. Numbers of circulating antibodies 3. Production of white blood cells 4. Myoglobulin levels
2. Numbers of circulating antibodies
Which drug is used during initial treatment for systemic anaphylaxis? 1. Dobutamine 250 mg IV 2. Diphenhydramine 50 mg IM 3. 1:1000 epinephrine 0.3 ml SC 4. Methylprednisolone 300 mg IV
3. 1:1000 epinephrine 0.3 ml SC
Which are diagnostic tests for immunodeficiency? 1. Antibody titer, bone scan 2. White blood cell count, hematocrit 3. Erythrocyte sedimentation rate, antibody titer 4. Complete blood count, serologic culture
3. Erythrocyte sedimentation rate, antibody titer
Hyposensitization therapy is most successful when used for persons who are allergic to: 1. Snake venom and foods 2. Shellfish and bee stings 3. Pollens and house dust 4. Trees and grasses
3. Pollens and house dust
Which laboratory findings will likely be encountered when caring for patients with autoimmune disorders? 1. Reduced red blood cell count 2. Elevated total serum complement levels 3. Presence of antinuclear or autoantibodies 4. Decreased erythrocyte sedimentation rate (ESR)
3. Presence of antinuclear or autoantibodies
Which nursing actions take priority when a person begins experiencing chills, tachycardia, and back pain during a transfusion? 1. Provide warm blankets and take the patient's temperature. 2. Administer oxygen and raise the head of the bed. 3. Stop the transfusion and notify the physician. 4. Assess vital signs and notify the laboratory.
3. Stop the transfusion and notify the physician.
Persons visiting an immunodeficient patient are advised to: 1. Leave if the patient begins coughing or sneezing 2. Make sure their immunizations are up to date 3. Wash their hands before entering the room 4. Wear gloves before touching the patient
3. Wash their hands before entering the room
Which nursing action facilitates effective airway clearance during an allergic reaction? 1.Turing the patient to the side 2.Increasing the patient's fluid intake 3.Placing the patient in a high Fowler's position 4.Percussing the patient's back during coughing episodes
3.Placing the patient in a high Fowler's position
Which objective data support the presence of hypersensitivity? 1. Reported exposure to a known allergen 2. Complaints of chest tightness 3. Familial history of allergies 4. Audible wheezing
4. Audible wheezing
Which is an appropriate gift for a neutropenic patient? 1. Potted mums 2. Fresh-cut flowers 3. A basket of fresh fruit 4. Flavored bottled water
4. Flavored bottled water
Which blood product can be safely administered to a patient with a history of febrile nonhemolytic reactions? 1. Whole blood 2. Packed red blood cells 3 .Fresh frozen red blood cells 4. Leukocyte-poor red blood cells
4. Leukocyte-poor red blood cells
Which is the best diet for a person with multiple myeloma? 1. High-phosphate, low-magnesium diet 2. High-potassium, high-fluid diet 3. High-calcium, low-purine diet 4. Low-calcium, low-purine diet
4. Low-calcium, low-purine diet
Which blood can the person with Rh-negative, type O blood receive safely? 1. A, B, AB, or O 2. A, B, or AB 3. AB or O 4. O
4. O
A nurse has administered a child's scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following? A) Natural immunity B) Active acquired immunity C) Cellular immunity D) Mild hypersensitivity
B (Feedback:Active acquired immunity usually develops as a result of vaccination or contracting a disease. Natural immunity is present at birth and provides a nonspecific response to any foreign invader. Immunizations do not activate the process of cellular immunity. Hypersensitivity is not an expected outcome of immunization.)
The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient? A) Postoperative delirium B) Postoperative dementia C) Senile dementia D) Senile confusion
A) Postoperative delirium
A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process? A) The cellular immune response B) Apoptosis C) Phagocytosis D) Opsonization
B (Feedback:Apoptosis, or programmed cell death, is the body's way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Opsonization is the coating of antigen-antibody molecules with a sticky substance to facilitate phagocytosis. The body does not use phagocytosis or the cellular immune response to remove cells from circulation.)
A patient is undergoing testing to determine the overall function of her immune system. What test can be performed to evaluate the functioning of the patient's cellular immune system? A) Immunoglobulin testing B) Delayed hypersensitivity skin test C) Specific antibody response D) Total serum globulin assessment
B (Feedback:Cellular (cell-mediated) immunity tests include the delayed hypersensitivity skin test, since this immune response is specifically dependent on the cellular immune response. Each of the other listed tests assesses functioning of the humoral immune system.)
A patient is admitted with cellulitis and experiences a consequent increase in white blood cell count. The nurse is aware that during the immune response, pathogens are engulfed by white blood cells that ingest foreign particles. What is this process known as? A) Apoptosis B) Phagocytosis C) Antibody response D) Cellular immune response
B (Feedback:During the first mechanism of defense, white blood cells, which have the ability to ingest foreign particles, move to the point of attack, where they engulf and destroy the invading agents. This is known as phagocytosis. The action described is not apoptosis (programmed cell death) or an antibody response. Phagocytosis occurs in the context of the cellular immune response, but it does not constitute the entire cellular response.)
A patient was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response? A) Effector B) Proliferation C) Response D) Recognition
B (Feedback:In the proliferation stage, T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. This does not occur in the response, recognition, or effector stages.)
A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this patient knows that the site of the injury will have an invasion of what? A) Interferons B) Phagocytic cells C) Apoptosis D) Cytokines
B (Feedback:Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken glass. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. Apoptosis, or programmed cell death, is the body's way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Cytokines are the various proteins that mediate the immune response. These do not migrate to injury sites.)
The nurse is assessing a client's risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity? A) The patient takes a beta blocker for the treatment of hypertension. B) The patient is under significant psychosocial stress. C) The patient had a pulmonary embolism 18 months ago. D) The patient has a family history of breast cancer.
B (Feedback:Stress is a psychoneuroimmunologic factor that is known to depress the immune response. Use of beta blockers, a family history of cancer, and a prior PE are significant assessment findings, but none represents an immediate threat to immune function.)
A patient's recent diagnostic testing included a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the patient's immunity? A) Humoral immune function B) Antigen recognition C) Cell-mediated immune function D) Antibody production
C (Feedback:A total lymphocyte count is a test used to determine cellular immune function. It is not normally used for testing humoral immune function and the associated antigen-antibody.)
A gerontologic nurse is caring for an older adult patient who has a diagnosis of pneumonia. What age-related change increases older adults' susceptibility to respiratory infections? A) Atrophy of the thymus B) Bronchial stenosis C) Impaired ciliary action D) Decreased diaphragmatic muscle tone
C (Feedback:As a consequence of impaired ciliary action due to exposure to smoke and environmental toxins, older adults are vulnerable to lung infections. This vulnerability is not the result of thymus atrophy, stenosis of the bronchi, or loss of diaphragmatic muscle tone.)
A patient is being treated for cancer and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which of the following ways? A) Causing apoptosis of cytokines B) Increasing interferon production C) Causing CD4+ cells to mutate D) Depressing antibody response
D (Feedback:Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. This specific nutritional deficit does not cause T-cell mutation, an increase in the production of interferons, or apoptosis of cytokines.)
During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess? A) Acquired immunity B) Natural immunity C) Phagocytic immunity D) Humoral immunity
A (Feedback:Acquired immunity usually develops as a result of prior exposure to an antigen, often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three means of defense. The first line of defense, the phagocytic immune response, involves the WBCs that have the ability to ingest foreign particles. A second protective response is the humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells that manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present at birth.)
An infection control nurse is presenting an inservice reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining? A) Agglutination B) Cellular immune response C) Humoral response D) Phagocytic immune response
A (Feedback:Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link between two antigens. This takes place within the context of the humoral immune response, but is not synonymous with it. Cellular immune response, the immune system's third line of defense, involves the attack of pathogens by T-cells. The phagocytic immune response, or immune response, is the system's first line of defense, involving white blood cells that have the ability to ingest foreign particles.)
The nurse is providing care for a patient who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment? A) Stem cell transplantation B) Serial immunizations C) Immunosuppression D) Genetic engineering
A (Feedback:Clinical trials using stem cells are under way in patients with a variety of disorders having an autoimmune component, including multiple sclerosis. Immunizations and genetic engineering are not used to treat multiple sclerosis. Immunosuppression would exacerbate symptoms of MS)
A patient with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the patient for which of the following complications of therapy? A) Immunosuppression B) Agranulocytosis C) Anemia D) Thrombocytopenia
A (Feedback:Corticosteroids such as prednisone can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts.)
A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of her last tetanus shot, which is over 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what? A) Antibodies B) Antigens C) Cytokines D) Phagocytes
A (Feedback:Immunizations activate the humoral immune response, culminating in antibody production. Antigens are the substances that induce the production of antibodies. Immunizations do not prompt cytokine or phagocyte production)
A patient has undergone treatment for septic shock and received high doses of numerous antibiotics during the course of treatment. When planning the patient's subsequent care, the nurse should be aware of what potential effect on the patient's immune function? A) Bone marrow suppression B) Uncontrolled apoptosis C) Thymus atrophy D) Lymphoma
A (Feedback:Large doses of antibiotics can precipitate bone marrow suppression, affecting immune function. Antibiotics are not noted to cause apoptosis, thymus atrophy, or lymphoma.)
A patient is vigilant in her efforts to "take good care of herself" but is frustrated by her recent history of upper respiratory infections and influenza. What aspect of the patient's lifestyle may have a negative effect on immune response? A) The patient works out at the gym twice daily. B) The patient does not eat red meats. C) The patient takes over-the-counter dietary supplements. D) The patient sleeps approximately 6 hours each night.
A (Feedback:Rigorous exercise or competitive exercise—usually considered a positive lifestyle factor—can be a physiologic stressor and cause negative effects on immune response. The patient's habits around diet and sleep do not present obvious threats to immune function.)
A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact that her bone marrow is unable to produce a sufficient amount of what?A) Lymphocytes B) Cytoblasts C) Antibodies D) Capillaries
A (Feedback:The white blood cells involved in immunity (including lymphocytes) are produced in the bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels)
A patient's exposure to which of the following microorganisms is most likely to trigger a cellular response? A) Herpes simplex B) Staphylococcus aureus C) Pseudomonas aeruginosa D) Beta hemolytic Streptococcus
A (Feedback:Viral, rather than bacterial antigens, induce a cellular response.)
A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this? A) The movement of B cells in and out of lymph nodes B) The interactions that occur between T cells and B cells C) The differentiation between different types of T cells D) The universal role of the complement system
B (Feedback:T cells interact closely with B cells, indicating that humoral and cellular immune responses are not separate, unrelated processes, but rather branches of the immune response that interact. Movement of B cells does not clearly show the presence of a unified immune system. The differentiation between types of T cells and the role of the complement system do not directly suggest a single immune system.)
A man was scratched by an old tool and developed a virulent staphylococcus infection. In the course of the man's immune response, circulating lymphocytes containing the antigenic message returned to the nearest lymph node. During what stage of the immune response did this occur? A) Recognition stage B) Proliferation stage C) Response stage D) Effector stage
B (Feedback:The recognition stage of antigens as foreign by the immune system is the initiating event in any immune response. The body must first recognize invaders as foreign before it can react to them. In the proliferation stage, the circulating lymphocyte containing the antigenic message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. In the response stage, the differentiated lymphocytes function either in a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader.)
The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication? A) Maintain the head of the bed at 45 degrees or higher. B) Encourage early ambulation. C) Encourage oral fluid intake. D) Perform passive range-of-motion exercises every 8 hours.
B) Encourage early ambulation.
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply. A) The patient wants you to teach a family member to do dressing changes. B) The patient expresses interest in the dressing change. C) The patient is willing to look at the incision during a dressing change. D) The patient expresses dislike of the surgical wound. E) The patient assists in opening the packages of dressing material for the nurse.
B, C, E
A patient requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this patient most likely has what type of immune disorder? A) A primary immune deficiency B) A gammopathy C) An autoimmune disorder D) A rheumatic disorder
C (Feedback: Primary immune deficiency results from improper development of immune cells or tissues. These disorders are usually congenital or inherited. Autoimmune disorders are less likely to have a genetic component, though some have a genetic component. Overproduction of immunoglobulins is the hallmark of gammopathies. Rheumatic disorders do not normally involve impaired immune function)
The nurse knows that the response of natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances the response of natural immunity? A) Cell cytoplasm B) Interstitial fluid C) Gastric secretions D) Cerebrospinal fluid
C (Feedback:Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi. Not all body fluids are chemical barriers, however. Cell cytoplasm, interstitial fluid, and CSF are not normally categorized as chemical barriers to infection.)
A nurse is reviewing a patient's medication administration record in an effort to identify drugs that may contribute to the patient's recent immunosuppression. What drug is most likely to have this effect? A) An antibiotic B) A nonsteroidal anti-inflammatory drug (NSAID) C) An antineoplastic D) An antiretroviral
C (Feedback:Chemotherapy affects bone marrow function, destroying cells that contribute to an effective immune response and resulting in immunosuppression. Antibiotics in large doses cause bone marrow suppression, but antineoplastic drugs have the most pronounced immunosuppressive effect. NSAIDs and antiretrovirals do not normally have this effect.)
Diagnostic testing has revealed a deficiency in the function of a patient's complement system. This patient is likely to have an impaired ability to do which of the following? A) Protecting the body against viral infection B) Marking the parameters of the immune response C) Bridging natural and acquired immunity D) Collecting immune complexes during inflammation
C (Feedback:Complement has three major physiologic functions: defending the body against bacterial infection, bridging natural and acquired immunity, and disposing of immune complexes and the byproducts associated with inflammation. Complement does not mark the parameters of the immune response; complement does not collect immune complexes during inflammation.)
A patient's current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by what cells? A) Suppressor T cells B) Memory T cells C) Cytotoxic T cells D) Complement T cells
C (Feedback:Cytotoxic T cells (also called CD8 + cells) participate in the destruction of foreign organisms. Memory T cells and suppressor T cells do not perform this role in the immune response. The complement system does not exist as a type of T cell.)
A nurse is admitting a patient who exhibits signs and symptoms of a nutritional deficit. Inadequate intake of what nutrient increases a patient's susceptibility to infection? A) Vitamin B12 B) Unsaturated fats C) Proteins D) Complex carbohydrates
C (Feedback:Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. As a result, the patient has an increased susceptibility to infection. Low intake of fat and vitamin B12 affects health, but is not noted to directly create a risk for infection. Low intake of complex carbohydrates is not noted to constitute a direct risk factor for infection.)
A patient is responding to a microbial invasion and the patient's differentiated lymphocytes have begun to function in either a humoral or a cellular capacity. During what stage of the immune response does this occur? A) The recognition stage B) The effector stage C) The response stage D) The proliferation stage
C (Feedback:In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader. In the recognition stage, the recognition of antigens as foreign, or non-self, by the immune system is the initiating event in any immune response. During the proliferation stage the circulating lymphocytes containing the antigenic message return to the nearest lymph node.)
A nurse is planning the assessment of a patient who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among what group? A) Young adults B) Native Americans C) Women D) Hispanics
C (Feedback:Many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones.)
A nurse is caring for a patient who has had a severe antigen/antibody reaction. The nurse knows that the portion of the antigen that is involved in binding with the antibody is called what? A) Antibody lock B) Antigenic sequence C) Antigenic determinant D) Antibody channel
C (Feedback:The portion of the antigen involved in binding with the antibody is referred to as the antigenic determinant. This portion is not known as an antibody lock, antigenic sequence, or antibody channel.)
A patient with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. What is the immune response that predominates in this situation? A) Humoral B) Nonspecific C) Cellular D) Mitigated
C Feedback:Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. During transplantation rejection, the cellular response predominates over the humoral response. Neither a mitigated nor nonspecific cell response is noted in this situation.)
The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident?A) Day 9 B) Day 7 C) Day 5 D) Day 3
C) Day 5
The nurse is assessing a new client with complaints of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder? A) Sickle cell disease B) Hemophilia C) Megaloblastic anemia D) Thrombocytopenia
C) Megaloblastic anemia
A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the client's bleeding and established that his vital signs are stable. What should be the nurse's next action? A) Position the client in a prone position to minimize bleeding B) Establish IV access for the administration of vitamin K C) Prepare for the administration of factor VIII D) Administer a normal saline bolus to increase circulatory volume
C) Prepare for the administration of factor VIII
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? A) Describe the appearance of the dressing in the electronic health record. B) Photograph the patients abdomen for later comparison using a smartphone. C) Trace the outline of the drainage on the dressing for future comparison. D) Remove and weigh the dressing, reapply it, and then repeat in 8 hours.
C) Trace the outline of the drainage on the dressing for future comparison.
The nurse is completing a focused assessment addressing a patient's immune function. What should the nurse prioritize in the physical assessment? A) Percussion of the patient's abdomen B) Palpation of the patient's liver C) Auscultation of the patient's apical heart rate D) Palpation of the patient's lymph nodes
D (Feedback:During the assessment of immune function, the anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement. If palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Because of the central role of lymph nodes in the immune system, they are prioritized over the heart, liver, and abdomen, even though these would be assessed.)
A nurse is planning a patient's care and is relating it to normal immune response. During what stage of the immune response should the nurse know that antibodies or cytotoxic T cells combine and destroy the invading microbes? A) Recognition stage B) Proliferation stage C) Response stage D) Effector stage
D (Feedback:In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader. The coupling initiates a series of events that in most instances results in total destruction of the invading microbes or the complete neutralization of the toxin. This does not take place during the three preceding stages.)
A nurse has admitted a patient who has been diagnosed with urosepsis. What immune response predominates in sepsis? A) Mitigated B) Nonspecific C) Cellular D) Humoral
D (Feedback:Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. For example, during transplantation rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant role. Neither mitigated nor nonspecific cell response is noted in this situation.)
A neonate exhibited some preliminary signs of infection, but the infant's condition resolved spontaneously prior to discharge home from the hospital. This infant's recovery was most likely due to what type of immunity? A) Cytokine immunity B) Specific immunity C) Active acquired immunity D) Nonspecific immunity
D (Feedback:Natural immunity, or nonspecific immunity, is present at birth. Active acquired or specific immunity develops after birth. Cytokines are proteins that mediate the immune response; they are not a type of immunity.)
A patient's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at a site of inflammation? A) Eosinophils B) Red blood cells C) Lymphocytes D) Neutrophils
D (Feedback:Neutrophils are the first cells to arrive at the site where inflammation occurs. Eosinophils increase in number during allergic reactions and stress responses, but are not always present during inflammation. RBCs do not migrate during an immune response. Lymphocytes become active but do not migrate to the site of inflammation.)
A nursing student is giving a report on the immune system. What function of cytokines should the student describe? A) Determining whether a cell is foreign B) Determining if lymphokines will be activated C) Determining whether the T cells will remain in the nodes and retain a memory of the antigen D) Determining whether the immune response will be the production of antibodies or a cell-mediated response
D (Feedback:Separate subpopulations of helper T cells produce different types of cytokines and determine whether the immune response will be the production of antibodies or a cell-mediated immune response. Cytokines do not determine whether cells are foreign, determine if lymphokines will be activated, or determine the role of memory T cells.)
A nurse is reviewing the immune system before planning an immunocompromised patient's care. How should the nurse characterize the humoral immune response? A) Specialized cells recognize and ingest cells that are recognized as foreign. B) T lymphocytes are assisted by cytokines to fight infection. C) Lymphocytesare stimulated to become cells that attack microbes directly. D) Antibodies are made by B lymphocytes in response to a specific antigen.
D (Feedback:The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. Phagocytosis and direct attack on microbes occur in the context of the cellular immune response.)
A patient is being treated for bacterial pneumonia. In the first stages of illness, the patient's dyspnea was accompanied by a high fever. Currently, the patient claims to be feeling better and is afebrile. The patient is most likely in which stage of the immune response? A) Recognition stage B) Proliferation stage C) Response stage D) Effector stage
D (Feedback:The immune response culminates with the effector stage, during which offending microorganisms are killed by the various actions of the immune system. The patient's improvement in health status is likely the result of this final stage in the immune response.)
Two units of PRBCs have been prescribed for a client who has experienced a GI bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting AIDS from a blood transfusion." How can the nurse best address the client's concerns? A) "All donated blood is treated with antiretroviral medications before it is used." B) "That did happen in some high-profile cases in the 20th century, but it is no longer a possibility." C) "HIV was eradicated from the blood supply in the early 2000s." D) "The chances of contracting AIDS from a blood transfusion are exceedingly low."
D) "The chances of contracting AIDS from a blood transfusion are exceedingly low."
The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response? A) There is a genetic link in the formation of deep vein thrombi. B) Hypervolemia is often present in patients who go on to develop deep vein thrombi. C) No known factors contribute to the formation of deep vein thrombi; they just occur. D) Dehydration is a contributory factor to the formation of deep vein thrombi.
D) Dehydration is a contributory factor to the formation of deep vein thrombi.
