Prep U for Brunner and Suddarth's Textbook of Medical Surgical Nursing, 13th Edition Chapter 35: Assessment of Immune Function

When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask?

"Have you ever received a blood transfusion?" pg. 982

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?

A cell-mediated response pg. 971

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 pg. 1779

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?

Acquired immunity pg.

While visiting the pediatric clinic with her 2 year old, a mother picks up a brochure about immunizations and asks about active and passive acquired immunity to childhood diseases. The nurse explains that immunizations are which of the following and why?

Active acquired immunity, because the person's own body develops defenses pg. 972

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

Anaphylaxis pg. 973

When an attenuated toxin is administered to a client, the B lymphocytes create memory cells that recognize the antigen if it invades the body at a future time. What kind of immunity is this?

Artificially acquired active immunity pg.

A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected?

Assess for ataxia using the finger-to-nose test and heel-to-shin test pg. 979

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

B lymphocytes pg. 972

An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response?

B lymphocytes produce antibodies that are specific to the pathogen. pg.

You are working on a transplant unit and you know to carefully monitor your clients. What is the rationale for closely monitoring clients taking immunosuppressive drugs?

Because of an increased risk of respiratory or urinary system infection pg.

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

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?

Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. pg. 978

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?

Corticosteroids pg. 1502

Which of the following is associated with impaired immunity in the aging patient?

Decreased renal function pg. 979

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

Humoral pg. 972

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 pg. 973

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 pg. 973

A mother has brought her child to the clinic for a wellness check. While talking with the nurse, the mother asks the nurse to suggest a diet that will maximize the immune function of her growing children. What dietary pattern should the nurse suggest?

Moderate diet that is balanced and varied pg. 980

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

Natural immunity pg. 971

Which type of cells destroys antigens already coated with antibody?

Null pg. 976

A patient is admitted with an infected leg, and the nurse notes an increase in his white blood cell (WBC) count. The nurse is aware that, during the immune response, pathogens are engulfed by WBCs that ingest foreign particles. What is this process known as?

Phagocytosis pg.

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells. pg. 971

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 pg. 982

What organ is considered lymphoid tissue?

Spleen pg. 971

The inflammatory response needs to be balanced so that what is helpful does not become harmful if mediators are secreted in excess. Which of the following are the primary mediators in an inflammatory response?

T cells and cytokines pg. 972

The nurse is beginning the physical examination of a client with a complaint of 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. pg. 65

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. pg. 588

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 pg. 978

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. pg. 978

What types of cells are the primary targets of the healthy immune system? Select all that apply.

infectious cells foreign cells cancerous cells pg. 970

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. pg. 1005

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 pg. 972

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

Naturally acquired active immunity pg. 972

A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?

Assure the client that this is a normal reaction pg. 984

The Family Nurse Practitioner is conducting a physical examination of a client with an immunity disorder. What would be an important parameter to examine?

Inspect the pharynx for large, red tonsils.

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 pg. 970-971.

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 pg. 1556

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." pg. 978

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 bone marrow." pg. 970

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) pg. 897

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 pg. 976

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

Exposure to foreign antigens may cause altered immune function. pg. 982

A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?

Naturally acquired active immunity pg.

During which stage of the immune response does the circulating lymphocytes containing the antigenic message return to the nearest lymph node?

Proliferation pg. 973

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

Renal function decreases pg. 979

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?

Naturally acquired active immunity pg. 972