Module 12 (Immunity)

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?" "Have you ever been treated for a sexually transmitted infection?" "When was your last menstrual period?" "Do you have abdominal pain or discomfort?"

"Have you ever received a blood transfusion?"

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system? Hematuria Ataxia Urinary frequency Burning upon urination

Ataxia

Which of the following cell types are involved in humoral immunity? B lymphocytes Helper T lymphocyte Suppressor T lymphocyte Memory T lymphocyte

B lymphocytes

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 skin and hair problems Because of an increased risk of blood-related complications Because of an increased risk of heart failure Because of an increased risk of respiratory or urinary system infection

Because of an increased risk of respiratory or urinary system infection

What type of cytokine will attract neutrophils and monocytes to remove debris? Suppressor T cells Lymphokines Cytotoxic T cells Regulator T cells

Lymphokines

The nurse is caring for a client with a suspected diagnosis of HIV. The nurse is preparing to draw blood for a confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before testing a client for HIV? Advise the client to take off any ornaments and metallic objects. Obtain a written consent from the client. Advise the client to avoid excess fluid intake. Advise the client to abstain from having intercourse.

Obtain a written consent from the client.

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 There is no immunity passed down from mother to child. Artificially acquired active immunity Naturally acquired active immunity

Passive immunity transferred by the mother

A client is diagnosed with multiple site cancers and has received whole-body irradiation. The nurse is concerned about a compromised immune system in this client for which reason? Radiation causes an excess of circulating lymphocytes. Radiation causes an excess of circulating hemoglobin. Radiation destroys lymphocytes. Radiation causes a deficiency of circulating hemoglobin.

Radiation destroys lymphocytes.

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 history of a splenectomy Surgical removal of the appendix Previous organ transplantation History of radiation therapy

Surgical removal of the appendix

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? Suppressor T cells B lymphocytes Macrophages T cells and cytokines

T cells and cytokines

The nurse is beginning the physical examination of a client with fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health? The client is alert and oriented to all spheres. The client appears mildly ill, listless, and disheveled. The client has palpable peripheral pulses in the upper extremities. The client has a blood pressure of 120/72 mm Hg.

The client appears mildly ill, listless, and disheveled.

You are caring for a client on tube feedings. The physician has ordered Osmolite HN as the feeding formula for the client. The family asks why the physician has ordered Osmolite HN instead of another formula to feed their family member. What is an important reason that tube-feeding formulas, such as Impact, Osmolite HN, or Peractive, be recommended to clients? To enhance the production of lymphocytes and NK cells To stimulate the immune system to attack tumor cells To block tumor necrosis factor To suppress immune system function

To enhance the production of lymphocytes and NK cells

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." "Currently, stem cell transplantation has only been performed in the laboratory, but future research with embryonic stem cell transplants for humans with immune dysfunction has been promising." "Stem cell clinical trials have only been attempted in clients with acquired immune deficiencies, but plans are underway to begin human cloning using embryonic stem cells." "Stem cell transplantation has been discontinued based on concerns about safety, efficacy, resource allocation, and human cloning."

"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."

A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse of having 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? Give the client one medicine at a time and observe for allergic reactions. Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. Administer the medications that the physician ordered. Call the pharmacy and let them know the client has several drug allergies.

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

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte. Suppressor T cell Cytotoxic T cell Memory T cell Helper T cell

Cytotoxic T cell

Which of the following protective responses begin with the B lymphocytes? Phagocytic Recognition Cellular Humoral

Humoral

What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction? IgE IgA IgG IgM

IgE

Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that: increase the efficacy of antibiotics. program T lymphocytes. filter bacteria from tissue fluid. eliminate cancer cells.

filter bacteria from tissue fluid.

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

infectious cells foreign cells cancerous cells

A client is informed of having a low white blood cell count and that the client 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." "White blood cells are produced in the thymus gland." "White blood cells are produced in the lymphatic tissue." "White blood cells are produced in the plasma."

"White blood cells are produced in the bone marrow."

The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine? A 32-year-old client who has never had chickenpox A 24-year-old client who is pregnant A 65-year-old client who had chicken pox when he was 12 years old A 17-year-old client who will be attending college and living in a dormitory

A 65-year-old client who had chicken pox when he was 12 years old

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide? Naturally acquired active immunity Artificially acquired active immunity Passive immunity Forced immunity

Artificially acquired active immunity

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 Review the urinalysis report for hematuria Assess joint mobility using passive range of motion. Assess for hepatosplenomegaly by measuring abdominal girth

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

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? Adalimumab (Humira) Etanercept (Enbrel) Epoetin alfa (Epogen) infliximab (Remicade)

Epoetin alfa (Epogen)

A 38-year-old client has been diagnosed with rheumatoid arthritis, an autoimmune disease. During the health history assessment. the nurse learns that the client works as an aide at a facility that cares for children infected with AIDS, does moderate cardiovascular exercises every other day, takes no medication, has no allergies, and eats mainly a vegetarian diet with fish and chicken one to two times each week. Which factor is the most important consideration in determining the status of the client's immune system? Age Diet Gender Environment

Gender

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. Measure the client's urine output. Inspect the joints for swelling or redness. Observe the client for physical deformities.

Inspect the pharynx for large, red tonsils.

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? Eosinophils Basophils Neutrophils Macrophages

Macrophages

A parent has brought a child to the clinic for a wellness check. While talking with the nurse, the parent asks the nurse to suggest a diet that will maximize the immune function of growing children. What dietary pattern should the nurse suggest? Diet rich in amino acids and essential fatty acids Diet rich in iron, zinc, and vitamin E Diet rich in potassium, magnesium, and sodium Moderate diet that is balanced and varied

Moderate diet that is balanced and varied

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? B cells Neutrophils Eosinophils Monocytes

Neutrophils

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? Apoptosis Phagocytosis Antibody response Cellular immune response

Phagocytosis

What is the function of the thymus gland? Programs T lymphocytes to become regulator or effector T cells Programs B lymphocytes to become regulator or effector B cells Develops the lymphatic system Produces stem cells

Programs T lymphocytes to become regulator or effector T cells

Which condition is associated with impaired immunity relating to the aging client? Incidence of autoimmune disease decreases Antibody production increases Renal function decreases Skin becomes thicker

Renal function decreases

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. Stem cell transplantation cannot restore immune system functioning. Stem cell transplantation has been performed in the laboratory only. Clinical trials are underway only in clients with acquired immune deficiencies.

The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

The nursing instructor is discussing the development of human immunodeficiency disease (HIV) with the students. What should the instructor inform the class about helper T cells? They are responsible for recognizing antigens from previous exposure and mounting an immune response. They have the ability to decrease B-cell production. They are activated on recognition of antigens and stimulate the rest of the immune system. They attack the antigen directly by altering the cell membrane and causing cell lysis.

They are activated on recognition of antigens and stimulate the rest of the immune system.

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: Lower margin around the liver. Upper left quadrant of the abdomen. Upper mediastinum. Lower right abdomen. SUBMIT ANSWER

Upper left quadrant of the abdomen.

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? colony-stimulating factor interleukins tumor necrosis factor interferons

interferons

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include: plasma cells and memory cells. neutrophils and monocytes. regulator T cells and helper T cells. lymphokines and suppressor T cells.

neutrophils and monocytes.

A client is diagnosed with an immune system disorder caused by a congenital alteration in the proper development of immune cells. The nurse is aware that this immune system disorder is classified as which type? primary immune deficiency gammopathy autoimmune deficiency hypersensitivity

primary immune deficiency

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? Apply ice packs to reduce the swelling Assure the client that this is a normal reaction Advise the client to use prescribed analgesics Gently rub the swollen area to accelerate blood flow

Assure the client that this is a normal reaction

A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following? The skin test was improperly performed. The solution used for the skin test was probably outdated. The client has only mild TB, which is not enough to cause a reaction. The client's immune system cannot mount a response to the skin test.

The client's immune system cannot mount a response to the skin test.

A nurse is caring for a client undergoing evaluation for possible immune system disorders. Which intervention will best help support the client throughout the diagnostic process? Encourage the client to ask the physician for information about treatment options for the possible diagnosis Accompany the client to the diagnostic tests Assist the client with scheduling the procedures Educate the client about the diagnostic procedures and answer their questions about the possible diagnosis

Educate the client about the diagnostic procedures and answer their questions about the possible diagnosis

Which type of immunity becomes active as a result of infection by a specific microorganism? Artificially acquired active immunity Naturally acquired passive immunity Artificially acquired passive immunity Naturally acquired active immunity

Naturally acquired active immunity

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 glucagon Plasma, which depletes the body's store of calcitonin Serum, which depletes the body's store of immunoglobulins Plasma, which depletes the body's store of catecholamines

Serum, which depletes the body's store of immunoglobulins

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 will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC). The nurse should send the client to have the blood drawn without informing him about the specific screening test. The nurse will call the client with the results of the test. The nurse ensures a written consent is obtained prior to testing.

The nurse ensures a written consent is obtained prior to testing.