NUR 3480

A client with multiple sclerosis is prescribed treatment with a monoclonal antibody. Which action(s) would the nurse add to the client's plan of care? Select all that apply.

Correct answer: Monitor for pulmonary edema. Assess for cytokine release syndrome. Explanation: The most serious adverse effects associated with the use of monoclonal antibodies are acute pulmonary edema (dyspnea, chest pain, wheezing), which is associated with severe fluid retention, and cytokine release syndrome (flu-like symptoms that can progress to third spacing of fluids and shock). Adverse effects of colony-stimulating factors include leukocytosis, alopecia, and gastrointestinal symptoms such as nausea, vomiting, diarrhea, constipation, and anorexia.

The nurse is caring for a client waiting for a heart transplant. The client's partner asks the nurse, "Why don't they just choose any heart until the right heart can be found?" What is the nurse's best response?

Correct response: "The more closely the new heart matches the client's tissue, the less aggressive the immune reaction will be." Explanation: Transplantation of foreign tissue (e.g., moving a heart from a donor to a sick client) results in an immune reaction. Matching a donor's human leukocyte antigen markers is important as closely as possible to those of the recipient because histocompatibility is essential. The more closely the transplanted heart matches the recipient, the less aggressive the immune response will be to the donated tissue. Graft versus host disease occurs only in stem cell or bone marrow donations, not organ transplantation. Suppressor T cells cannot be transfused like blood because they must be produced by the body to function appropriately.

The nurse is caring for a client who is immunocompromised and is explaining the function of cytotoxic T cells. What should the nurse explain to this client?

Correct response: "These T cells can either destroy a foreign cell or mark it for aggressive destruction by another". Explanation: Effector or cytotoxic T cells either destroy a foreign cell or make it available for aggressive destruction. Cells that identify specific proteins or antigens are B cells. Cells that respond to chemical indicators to stimulate other cells are helper T cells. Cells that suppress or slow the reaction are suppressor T cells.

While studying the T- and B-cell immune suppressors, the nursing students learn that the most commonly used immune suppressant is:

Correct response: Cyclosporine . Explanation: Several T- and B-cell immune suppressors are available for use. Of the numerous agents available, cyclosporine is the most commonly used immune suppressant. The other options are all T- and B-cell immune suppressors; they are just not the most commonly prescribed.

A client comes to the clinic asking what hematopoiesis means. How should the nurse explain this to the client?

Correct response: Hematopoiesis means undifferentiated stem cells are stimulated to become specific blood cells. Explanation: Hematopoiesis means undifferentiated stem cells are stimulated to become specific blood cells. Not stimulating the cell, stimulating undifferentiated cells, and stimulating the production of nonspecific blood cells would not produce a therapeutic effect. Reference: Frandsen, Geralyn, & Smith Pennington. Chapter 13: Drug Therapy to Suppress Immunity, OVERVIEW OF ALTERED IMMUNE FUNCTION, p. 226.

A client is experiencing an allergy to a penicillin antibiotic. What immunoglobulin (Ig) will most directly relate to this immune response?

Correct response: IgE Explanation: Five different types of immunoglobulins have been identified: IgE is present in small amounts and seems to be related to allergic responses and to the activation of mast cells. The first immunoglobulin released is M (IgM). It contains the antibodies produced at the first exposure to the antigen. IgG, another form of immunoglobulin, contains antibodies made by the memory cells that circulate and enter the tissue; most immunoglobulin found in the serum is IgG. IgA is found in tears, saliva, sweat, mucus, and bile. It is secreted by plasma cells in the GI and respiratory tracts and in epithelial cells. These antibodies react with specific pathogens that are encountered in exposed areas of the body. Reference: Frandsen, Geralyn, & Smith Pennington, FUNCTION-Clinical Manifestations, p. 227. Chapter 13: Drug Therapy to Suppress Immunity

A client has developed a wound infection and leukocytes are leaving the bloodstream to perform phagocytosis on pathogens. What white cells are most likely performing this function?

Correct response: Neutrophils Explanation: When an injury or invasion occurs, neutrophils are rapidly produced and move to the site of insult to attack the foreign substance. Basophils are not capable of phagocytosis but contain chemicals that can initiate or maintain an immune response and may be fixed or circulate in the blood. Eosinophils are not well understood but are often found at the site of an allergic reaction. Monocytes are capable of phagocytosis and show up in greater numbers after the neutrophils to remove debris.

A client who has been diagnosed with a compromised immune system is eager to know about the condition. Which explanation should the nurse provide regarding the potential consequences of a compromised immune system?

Correct response: Results in immunodeficiency diseases Explanation: The nurse should inform the client that a compromised immune system will result in immunodeficiency diseases. An overactive immune system results in allergies and autoimmune disorders and not a compromised immune system. A compromised immune system does not deplete the thymic humoral factor and does not specifically result in cell-mediated immunity. T cells produce cell-mediated immunity when they proliferate and become sensitized.

A female client is prescribed cyclosporine after her bone marrow transplant. What is the mechanism of action of cyclosporine that makes this an ideal drug for this patient?

Correct response: Suppression of the normal effects of the immune system in the body Explanation: Cyclosporine acts as an immune suppressant, which blocks the normal effects of the immune system in the body. This action is beneficial in organ transplantation, in which the body destroys foreign tissue, and in autoimmune diseases, in which the body destroys its own cells.

The nurse is caring for a client taking a cytotoxic immunosuppressant drug for the treatment of an autoimmune disorder. What education provided by the nurse will address the therapeutic effect of the medication? Practice meticulous hygiene and wash hands often and thoroughly Eat a diet high in carbohydrates and proteins Avoid strenuous exercise Get sun exposure to boost vitamin D supplementation

Practice meticulous hygiene and wash hands often and thoroughly People taking medications that suppress the immune system are at high risk for development of infections. As a result, patients, caregivers, and others in the patient's environment need to wash their hands often and thoroughly, practice meticulous personal hygiene (e.g., take good care of the mouth, gums, and skin), avoid contact with infected people, and practice other methods of preventing infection. Dietary habits should be encouraged to eat a balanced, nutritious meal plan and not high in carbohydrates and proteins. Exercise is not limited and should be performed. Sun exposure should be reduced and the use of sunscreen and protective clothing is encouraged.