Adult health exam 6 prep u
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?"
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. What advice should the nurse give to calm the client?
Assure the client that this is a normal reaction.
Which of the following inhibits bone resorption and promotes bone formation?
Calcitonin
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?
The client is under significant psychosocial stress.
The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of
anemia.
An infection control nurse is presenting an in-service 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?
Agglutination
Which response is a humoral immune response?
Anaphylaxis
A nurse practitioner working in a dermatology clinic finds an open lesion on a client who is being assessed. What should the nurse do next?
Assess the characteristics of the lesion.
A client undergoing a skin test has been interterm -21adermally 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 Which condition is associated with impaired immunity relating to the aging client?
Which of the following cell types are involved in humoral immunity?
B lymphocytes
An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis?
Bone fracture
Which term describes the transfer of heat from the body to a cooler object in contact with it?
Conduction
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.
Cytotoxic T cell
A client's current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by what cells?
Cytotoxic T cells
A client's electronic health record states that the client receives regular transfusions of factor IX. The nurse would be justified in suspecting that this client has what diagnosis?
Hemophilia
Which of the following protective responses begin with the B lymphocytes?
Humoral
When the body is in contact with an allergen, this lymphocyte, located in the respiratory and intestinal mucosa, triggers the release of histamine. Choose that lymphocyte.
Ig E
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 her bone marrow is unable to produce a sufficient amount of what?
Lymphocytes
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
What is the function of the thymus gland?
Programs T lymphocytes to become regulator or effector T cells.
The nurse knows that a patient who presents with the symptom of "blanching of fingers on exposure to cold" would be assessed for what rheumatic disease?
Raynaud's phenomenon
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?
The interactions that occur between T cells and B 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
T-cell deficiency occurs when which gland fails to develop normally during embryogenesis?
Thymus
A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of:
lymphocytes.
A client is taking immunosuppressive medications to prevent the rejection of a transplanted kidney. Which adverse effect(s) should the nurse closely monitor in this client?
respiratory or urinary system infections
Which findings from a nail assessment are considered abnormal? Select all that apply.
spooning clubbing
An emergency department (ED) nurse has provided care for many patients who have primary and secondary diagnoses of immune dysfunction. Which of the following patients likely has the highest risk of a disruption to normal immune functioning?
A man who has recently completed medical treatment for prostate cancer
The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present?
All body fluids
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.
A client has undergone treatment for urosepsis and received high doses of numerous antibiotics during the course of treatment. When planning the client's subsequent care, the nurse should be aware of what potential effect on the client's immune function?
Bone marrow suppression
Diagnostic testing has revealed a deficiency in the function of a client's complement system. This client is likely to have an impaired ability to do what action?
Bridge natural and acquired immunity
The nurse is performing a comprehensive assessment of a client's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way?
By palpating the client's skin
Which group is at the greatest risk for osteoporosis?
Caucasian women
A nurse is teaching a client with osteomalacia about the role of diet. What would be the best choice for breakfast for a client with osteomalacia?
Cereal with milk, a scrambled egg, and grapefruit
The nurse in an ambulatory care center is admitting an older adult client who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what?
Cherry angiomas
Which of the following is a age-related change associated with the immune system?
Decreased antibody production
A client 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 what way?
Depressing antibody response
A client is fighting an active infection. What function will cytokines perform in this immune response?
Determining whether the immune response will be the production of antibodies or a cell-mediated response
All the following items are related to cancer. Which does not affect the immune system?
Diagnostic tests for cancer
A clinic nurse is caring for a client with suspected gout. While explaining the pathophysiology of gout to the client, what should the nurse explain?
Increased uric acid levels
A 6-year-old client is diagnosed with a viral infection of the respiratory system. Which will most likely be trying to fight the antigen?
Interferons
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
Which is an action of cytotoxic T cells?
Lyse cells infected with virus
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 nurse is assessing a client with rheumatoid arthritis. The client expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurse's response to the client?
Most CAM therapies lack sufficient evidence to support them.
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
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
Which condition is associated with impaired immunity relating to the aging client?
Renal function decreases
A client with rheumatic disease has developed a gastrointestinal bleed. The nurse caring for the client should further assess the client for the adverse effects of what medications?
Salicylate therapy
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 nurse is planning the assessment of a client 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?
Women
A nurse is reviewing a client's medication administration record in an effort to identify drugs that may contribute to the client's recent immunosuppression. What drug is most likely to have this effect?
An antineoplastic
A client requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this client most likely has what type of immune disorder?
An autoimmune disorder
A public health nurse is planning community teaching for a group of older adults regarding aging and hematological conditions. What condition will the nurse identify as most common among this population?
Anemia
A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization which will allow for the release of what?
Antibodies
A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response?
Antibodies are made by B lymphocytes in response to a specific antigen.
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
A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?
Ecchymoses
A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?
Ensuring adequate exposure to sunlight
Our bodies contain a variety of immunoglobulins. Which of these immunoglobulins is found in sweat, tears, mucus, and bile?
IgA
What immunoglobulin is present in small amounts and is thought to be related to allergic responses?
IgE
A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which of the following complications of therapy?
Immunosuppression
While hospitalized, a client accidentally injures his finger and begins to bleed. What substance does the nurse recognize as naturally rushing to the site of injury before any other action takes place?
Platelets
An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate?
Stool for occult blood
The health care team is caring for a client with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What treatment should the nurse anticipate?
Supplemental calcium and increased doses of vitamin D
In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation?
Surgical debridement
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
A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication?
Take the medication with food to avoid stomach upset.
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.
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
Immunoglobulins (also known as antibodies) promote the destruction of invading cells in various ways, using different mechanisms. Which mechanism is used by immunoglobulins to destroy pathogenic antigens?
All options are correct.
The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms?
Chronic fatigue, generalized muscle aching, and stiffness
A client's 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 natural immunity?
Gastric secretions
A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient?
Jaundice
Which type of immunity becomes active as a result of infection by a specific microorganism?
Naturally acquired active immunity
Upon reviewing the results of a complete blood count on a patient who is diagnosed with an acute infection what will the nurse expect to see elevated?
Neutrophil count
The nurse is aware that a patient has been diagnosed with thrombocytopenia. Which of the following is the most typical first indicator of the diagnosis that a patient will exhibit?
Petechiae
The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action?
Walk or perform weight-bearing exercises outdoors
What types of cells are the primary targets of the healthy immune system? Select all that apply.
infectious cells foreign cells cancerous cells
The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction?
Disposing of the blood container and tubing in biohazard waste.
The nurse is obtaining a history from a patient with severe psoriasis. What question would be the most important to ask this patient to determine a genetic predisposition?
Does anyone in your family have more than one autoimmune disease?"
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
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 client knows that the site of the injury will have an invasion of what?
Phagocytic cells
A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a storm door. The fall resulted in a 6 cm laceration of the right antecubital. The nurse caring for this patient knows that the site of the injury will have an invasion of what?
Phagocytic cells
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
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
The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following?
Spleen
The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?
The client is having a febrile nonhemolytic reaction.
A client is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize?
The need to report any signs or symptoms of infection promptly
During the immune response, cytotoxic cells bind to invading cells, destroy the targeted invader, and release lymphokines to remove the debris. Which type of T-cell lymphocyte is cytotoxic?
effector T cells
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
A 15-year-old pubescent male is undergoing a sports physical for school. What type of hair is growing in this client's axilla, face, arms, chest, etc. due to the hormones coursing through his body?
terminal
During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses:
acquired immunity.
Which immunity type becomes active as a result of infection by a specific microorganism?
naturally acquired active immunity
The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells?
The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells.
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
neutrophils and monocytes.
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.
