Immunity, infection, inflammation

A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes this result?

"The result indicates that you are infected with the tuberculosis organism."

The nurse is collecting case reports that can be analyzed using the failure mode effective analysis (FMEA) tool. Which case files would the nurse collect? Select all that apply. One, some, or all responses may be correct.

- Retained foreign body left during surgery that was removed immediately - Wheelchair-bound client rescued from falling in the corridor of the hospital - Urinary tract infection after 4 days of continuous catheterization

A nurse is teaching about near-miss events to a group of nursing students. What is appropriate for the nurse to include in the education? - They do not cause actual harm to the patient. - They may cause moderate harm to the patient. - They are caused by a variation in standard care. - They are caused by impaired immune functioning. - Their cause can be analyzed by failure mode effective analysis

- They do not cause actual harm to the patient. - They are caused by a variation in standard care. - Their cause can be analyzed by failure mode effective analysis

The nurse instructs a client who avoids bathing to take a bath or shower each day as a means of maintaining hygiene and preventing infection. Which of these reactions should the nurse expect if the client is in the action stage? Select all that apply.

-I try to take a shower every day, but I skip it sometimes because of my tight work schedule. -I understand that bathing regularly is a good habit, but my bathroom is very cold in the mornings -I want to take a bath regularly, but I don't have time because I need to look after my kids and my parents.

Which tasks should a nurse perform in order to comply with public health laws?

-Report cases of communicable diseases -Report incidences of domestic violence -Ensure that clients in a community have received necessary immunizations

Which examples mentioned by the nurse belong to the third level of needs according to Maslow's hierarchy? Select all that apply. One, some, or all responses may be correct

-a client is depressed because his or her spouse has passed away -a client wants to reconnect with old friends after being diagnosed with cancer -a client never goes to family gatherings because he or she is not accepted by family members

Which intervention with the nurse anticipate incorporating into the plan of care for a client with bursitis of the left knee? Select all that apply. 1. Rest the affected joint 2. apply a heat pack 3. use a compression splint 4. do a gentle range of motion exercise 5. take a nonsteroid anti-inflammatory drug (NSAIDS) as needed for pain

1, 3, 5

Arrange in order the steps involved in skin testing for an allergen causing a type I allergic reaction

1. Discontinue corticosteroid medications. 2. Clean the inner side of the forearm with soap and water 3. Place drops of Sera containing the known allergen on skin 4. Use a skin testing needle to scratch the surface of the skin 5. Observe for a wheal formation on the skin 6. Apply topical steroid on the skin

Place in order the steps the nurse would follow when developing a protocol in the electronic health record for clients with indwelling urinary catheters to decrease the risk of urinary tract infections.

1. Meets with the nursing staff 2. Selects an assessment tool 3. Interviews the nursing staff 4. Designs the assessment screens 5. Evaluates and determines data 6. Selects a standardized language 7. Adds a decision support rule

A nurse is teaching Unlicensed Assistive Personnel (UAP) about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? 1.Handwashing before and after providing client care. 2.Cleaning all equipment with an approved disinfectant after use. 3.Wearing personal protective equipment (PPE) when providing client care. 4.Using medical and surgical aseptic techniques at all times

1.Handwashing before and after providing client care.

Arrange the steps required to stimulate antibody-mediated immunity in its correct sequence.

1.Invasion of new antigens in the body 2.Interaction of the macrophage and helper T-cells to recognize the antigen 3.Sensitization of B-lymphocyte to the new antigen 4.Production of antibodies by B-lymphocytes 5.Binding of antibodies to the antigen and formation of immune complex 6.Neutralization or elimination of the antigen

The nurses in a health care facility have developed a new care plan to prevent the risk of infection in clients with an indwelling urinary catheter in place. To determine if the changes prevent infections, the nurse manager uses the plan-do-study-act. Place in order the steps that the nurse manager would follow to evaluate the charges.

1.Plan to test the change 2.Try out the change 3. Analyze what happened from the change 4. Determine what was learned

Arrange the pathophysiologic events of acne in the correct sequence. 1.Immune response and inflammation 2.Excessive sebum production 3.Alterations in follicular growth and differentiation 4.Colonization of Propionibacterium acnes

2, 3, 4, 1 Excessive sebum production occurs with the maturation of adrenocortical glands. This action is followed by alterations in follicular growth and differentiation. Propionibacterium acnes proliferate and increase in number. This proliferation leads to an accumulation of neutrophils, which causes the formation of papules, pustules, nodules, and cysts and subsequent inflammation.

The nurse is caring for a patient with diabetes mellitus who is on insulin therapy. After the patient experiences a cardiac arrest, the patient is transferred to the intensive care unit (ICU). Which nursing interventions are the major attributes that affect the quality of care provided to the patient? 1. Multiple selection question Develop a diet plan according to the patient's food preference. 2. Coordinate with the members of the ICU while transferring the patient. 3. Provide cardiopulmonary resuscitation before transferring the patient. 4. Encourage the patient's family members to visit the patient frequently. 5. Administer digoxin (Cardoxin) to the patient according to the prescription

2, 3, 5

which nursing intervention would prevent septic shock in the hospitalized client? 1 Maintain the client in a normothermic state. 2 Administer blood products to replace fluid losses. 3 Use aseptic technique during all invasive procedures. 4 Keep the critically ill client immobilized to reduce metabolic demands.

3 Use aseptic technique during all invasive procedures.

A nurse caring for a client post-surgery takes necessary steps to achieve quality client care. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called informatics? Select all that apply. 1 Washing the hands before handling the client's incision site 2 Implementing a new method of monitoring the client's incision site for infections 3 Documenting in the electronic health record (EHR) after performing wound debridement 4 Locking the electronic health record (EHR) after every entrance of necessary information 5 Using computer-assisted instruction (CAI) program to provide better quality of care to the client

3, 4, 5

Which is the correct response to a parent whose child is undergoing chemotherapy and is not up to date on immunizations for school? 1. "By this time your child has developed sufficient antibodies to provide immunity." 2. "Maintaining current immunizations is critical. Make sure the series is completed." 3. "This isn't the best time to finish the immunizations, because your child's immune system is suppressed." 4. "It's important to complete the immunizations because your child needs to be protected from childhood diseases that could be fatal."

3. "This isn't the best time to finish the immunizations, because your child's immune system is suppressed."

The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond? 1"A newborn's spleen can't produce efficient antibodies." 2"Infants younger than 2 months are rarely exposed to infectious disease." 3"The immunization will attack the infant's immature immune system and cause the disease." 4"Maternal antibodies interfere with the development of active antibodies by the infant when immunized."

4 Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases.

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1.All nursing functions will be completed by discharge. 2.All invasive intravenous lines will remain patent. 3.The client will remain awake, alert, and oriented at all times. 4.The client will be free of signs and symptoms of infection by discharge.

4.The client will be free of signs and symptoms of infection by discharge.

The nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which clinical findings to this disease can the nurse expect the client to exhibit? Select all that apply. A. Butterfly facial rash B. Firm skin fixed to tissue C. Inflammation of the joints D. Muscle mass degeneration E. Inflammation of

A and C

Which conditions in clients are examples of cell-mediated immunity? Select all that apply. A. Tuberculosis B. Graft rejection C. Allergic rhinitis D. Contact dermatitis E. Anaphylactic shock

A, B, D Conditions such as tuberculosis, graft rejection, contact dermatitis, and fungal infections are examples of cell-mediated immunity. T lymphocytes and macrophages sensitize T cells and cytokines to provide protection against fungus, viruses (intracellular), chronic infectious agents, and tumor cells. Allergic rhinitis and anaphylactic shock are examples of humoral immunity that are mediated by antibodies released by B lymphocytes.

Which type of immunity would a 4-year-old child develop during the course of an infection with varicella?

Active natural immunity

Which nursing intervention is the priority when a client receiving chemotherapy develops a temperature develops a temperature of 102.2 when the temperature 6 hours ago 99.2?

Administer the prescribed antipyretic and notify the primary health care provider of this change.

What strategies should the nurse apply during vaccination to reduce pain and anxiety? Select all that apply.

Applying a topical anesthetic Injecting the most painful vaccine last Holding the child upright during the vaccination Administering intramuscular injections rapidly without prior aspiration

When assessing risk factors, which question would the nurse ask a client who has developed pneumonia?

Are you a diabetic?

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later the client is admitted to the hospital with the diagnosis of tetanus. Which statement describes the nurses responsibility in this situation?

Assessment by the nurse was incomplete and as a result the treatment was insufficient

What complication would the nurse monitor for in a client on strict bed rest for 3 days?

Atelectasis hypotension constipation pressure injuries urinary tract infections

Which condition triggers humoral immunity?

Atopic diseases, Bacterial infection, Anaphylactic shock

A nurse is changing the dressing of a postoperative patient. Another client has fallen down near the nursing station and is unconscious. What is the priority nursing action in this situation?

Attend to the patient who lost consciousness. Loss of consciousness may pose a threat to the patient's safety and survival, and is a high-priority need. Therefore, the nurse should attend to the unconscious patient.

Which information will the nurse consider when planning care for our client with human immune deficiency virus who has been diagnosed with class 3 tuberculosis?

Class 3 tuberculosis is a clinically active disease which is contagious. Tuberculosis is the leading cause of morality in clients infected with HIV. Persons with active tuberculosis are usually treated on an outpatient basis.

The nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media?

Complete the entire course of antibiotic therapy. Once antibiotic therapy is initiated, the antibiotics start to destroy specific bacterial infections that the healthcare provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria have a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse should not discourage use of herbal fever remedies; however, the herbal treatment should be reviewed to see if it is contraindicated. Ampicillin should be taken 1 to 2 hours after meals. Antibiotic therapy should be completed as prescribed.

A client with a methicillin-resistant Staphylococcus aureus infected wound is scheduled for a computed tomography scan. To ensure client and visitor safety during transport, the nurse would implement which precaution?

Cover the infected site with a dressing

Which meal is most appropriate for a client with a large pressure injury? a. Hamburger with french fries b. Turkey meatloaf with brown rice c. Pasta and tomato sauce with a side salad d. Grilled chicken, steamed spinach, and a side of orange slices

D

Which client would the nurse suspect is having a type IV hypersensitive reaction when providing care for four clients with hypersensitivity reactions? A. IgE: Wheal and flare B. IgM: None C. IgG: Erythema after four hours D. None: Erythema and edema after 24 hours

D. None: Erythema and edema after 24 hours Type IV or delayed hypersensitive reactions are cell-mediated immune responses that involve T lymphocytes, not antibodies. These cause erythema and edema in client D within 24 to 48 hours after a skin test. Type I hypersensitivity reaction is known as an anaphylactic reaction mediated by IgE antibodies; it shows wheal and flare around the site of injection in client A. Type II hypersensitivity reactions are known as cytotoxic reactions that involve IgM and IgG antibodies and show no response to the skin test in client B. Type III hypersensitivity reactions are known as immune-complex reactions that involve IgG and IgM antibodies. These show erythema and edema after 3 to 8 hours of a skin test in client C.

Which describes the purpose of preoperative antibiotics for a client scheduled for surgical resection of the colon and creation of a colostomy?

Decrease bacteria in the intestines

Which function of the leukocytes is involved in inflammation process?

Destruction of bacteria and cellular debris. Release of vasoactive amines during allergic reactions.

Which infection would the nurse monitor for in the toddler based on structural characteristics at this age? Select all that apply.

Ear infection, Acute sinusitis, Laryngotracheobronchitis, Inflammation of the tonsils

The nurse is preparing to insert an intravenous catheter in a thin emaciated client who is scheduled to begin intravenous fluid therapy. Which interventions would the nurse follow to provide high quality care?

Flush the Ivy line with normal saline. Stop the insertion procedure when there is a break in technique

Which education would the nurse provide the parent of a 2-month-old infant about home care in the event of an immunization reaction?

Give acetaminophen for fever call the health care provider if the child exhibits marked drowsiness or seizures.

A client who has rheumatoid arthritis participates in an individualized exercise program daily. Which statement from the client indicates to the nurse that the client understands the purpose of the program?

I do one set of exercises slowly after breakfast, then I space the rest of them throughout the day

After teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections comma which client statement indicates effective learning?

I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia.

Which factor explains why client who experiences an acute episode of rheumatoid arthritis have swollen finger joints?

Inflammation in the joint's synovial lining

Which disease process places a client at an increased risk for infection?

Leukemia, Lymphoma, Emphysema

A 5-month-old infant is brought to the pediatric clinic because of exposure to an adolescent sibling with measles. Which factor would the nurse consider when determining the infants risk of infection?

Maternal diseases and immunizations

Which leukocyte would the nurse include when teaching about antibody meditated immunity?

Memory cell, B-lymphocyte

After instructing an older clients adult child about age-related immune system changes and associated care measures which statement indicates a need for further instruction?

My parent comes in for checkups only when experiencing a fever.

Which action would the nurse instruct and other client to implement to ensure antibody meditated immunity?

Obtain a shingles vaccination. Receive a tetanus booster injection. Obtain the pneumococcal vaccination. Receive an annual influenza vaccination.

Which therapeutic outcomes are expected after administering ibuprofen? Select all that apply. One, some, or all responses may be correct.

Pain relief Temperature reduction Reduced inflammation Prostaglandins accumulate at the site of an injury, causing pain; nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen inhibit COX-1 and COX-2 (both are isoforms of the enzyme cyclooxygenase), which inhibit the production of prostaglandins, thereby contributing to analgesia. NSAIDs inhibit COX-2, which is associated with fever, thereby causing the temperature to decline. NSAIDs inhibit COX-2, which is associated with inflammation, thereby reducing inflammation. NSAIDs do not cause diuresis; reversible renal ischemia and renal insufficiency in clients with heart failure, cirrhosis, or hypovolemia can be potential adverse effects of NSAIDs. NSAIDs do not cause bronchodilation. Anticoagulation is an adverse effect, not a desired outcome; NSAIDs can impair platelet function by inhibiting thromboxane, an aggregating agent, resulting in bleeding.

The nurse is caring for a client with chronic inflammation of the bowel. For which most serious complication would the nurse monitor in this client?

Perforation

Which recommendation would the nurse make to the family of a child with juvenile idiopathic arthritis who has difficulty getting ready for school in the morning due to joint pain and stiffness?

Provide warm, moist heat to the affected joints before arising.

Identify the clinical manifestation associated with the release of histamine during a type one rapid hypersensitivity reaction. Select all that apply.

Pruritus, Erythema, Nasal mucus secretion, Conjunctival mucus secretion

Which instruction indicates a lack of understanding of a nurse teaching a human immune deficiency virus positive client about strategies to prevent opportunistic infections?

Purchase organic unpasteurized apple cider for your vitamin C requirements

Which option is an example of actively acquired specific immunity?

Recovery from measles Recovery from chickenpox Immunization with live or killed vaccines

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse assesses the vital signs. Which vital sign assessments require reassessment? Select all that apply.

Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mmHg Oxygen saturation of 95% In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings. Therefore, the registered

The nurse is caring for a client 1 week after a client had an above-the-knee amputation. To control edema of the residual limb, the nurse should plan to take which action?

Rewrap the elastic bandage as necessary.

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client?

Salmonellosis

Which findings noted during assessment would lead the nurse to determine that a client is at an increased risk for infection?

Surgical incision, Urinary catheter, Antibiotic therapy, Intravenous access

The nurse is preparing discharge instructions for a client that acquired a nosocomial infection, Clostridium difficile. What should the nurse include in the instructions?

The infection causes diarrhea accompanied by flatus and abdominal discomfort. Rationale:The main clinical manifestation of Clostridium difficile is diarrhea accompanied by excessive flatus and abdominal discomfort. Nausea and vomiting is not associated with this infectious disease. Clients should follow a nutritionally balanced diet high in fiber and low in fats with no specific restrictions. Cleaning and disinfection of items in the home is key to preventing spread of the infection because the C. difficile spore is relatively resistant

Which response would the nurse provide during an education session at the local Community Center to a question asking why influenza vaccines are needed annually?

The nature of the virus changes every year, the vaccine is developed based on the most prevalent type and variant being seen

Which scenario would the nurse consider an output component of the nursing process?

The nurse notices the client's wounds healed after performing regular wound debridement. When changing the surgical site dressing, the nurse notices the client developed an infection. The nurse finds the client's blood pressure increased, even with timely medication administration.

The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infection?

To the client from outside sources

While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. What might be the reason behind this condition?

Trauma Paronychia is an abnormality of the nail bed. The condition is marked by inflammation of the skin at the base of the nail; this condition may be caused by trauma or a local infection. Trichinosis is associated with red or brown linear streaks in the nail bed. Pulmonary diseases can cause changes in the angle between nail and nail base, which is a phenomenon known as clubbing. Koilonychia, a concave curvature of the nails, may occur as a result of iron-deficiency anemia.

Which type of delayed hypersensitivity reaction does the client pictured in the image likely have?

Type IV

Which assessment findings would the nurse identify in a client with clinical manifestations of rheumatoid arthritis (RA)? Select all that apply. One, some, or all responses may be correct. a. Obesity and asymmetric joint disease b. Development of antinuclear antibodies c. Inflammatory disease pattern d. Bilateral involvement of metacarpophalangeal joints e. Disease process involving the distal interphalangeal joints f. Disease in the weight-bearing joints and hand

b, c, d

Which response would the nurse gives a client taking ibuprofen for rheumatoid arthritis who asked the nurse if acetaminophen can be substituted?

ibuprofen has anti-inflammatory properties comma and acetaminophen does not.