NCO Immunity Master
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is the priority? Urinary output Sensation to touch Neurological status Respiratory exchange
The ascending paralysis of Guillain-Barre syndrome can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurological status are important, none of them are the priority.
Which virus is responsible for causing infectious mononucleosis in clients? Parvovirus Coronavirus Rotavirus Epstein-Barr virus
Epstein-Barr virus is responsible for mononucleosis and possibly Burkitt lymphoma. Parvovirus and rotavirus cause gastroenteritis. Coronavirus causes upper respiratory tract infections.
Which key feature indicates malignancy in a client with acute immunodeficiency syndrome (AIDS)? Dry skin Weight loss Kaposi sarcoma Opportunistic infections
Kaposi sarcoma is a key feature that indicates malignancy in an AIDS client. Dry skin is an integumentary manifestation in a client suffering from AIDS. Weight loss is a gastrointestinal manifestation in a client with AIDS. Opportunistic infection is an immunological manifestation in a client with AIDS.
Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. One, some, or all responses may be correct. Asthma Hay fever Sarcoidosis Myasthenia gravis Rheumatoid arthritis
Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions mediated by a reaction between IgE antibodies with antigens. Type I hypersensitivities result in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis are a result of reactions between sensitized T cells and antigens. Myasthenia gravis results from a type II hypersensitivity reaction due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction resulting in inflammation from the formation of immune complexes between antigens and antibodies.
Which client's report indicates acquired immunodeficiency syndrome (AIDS)?
The diagnosis of AIDS requires that the person should be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm 3 (200 cells/(L) or less than 14% or an opportunistic infection. Client 3, with a CD4+ T-cell count of less than 200 cells/mm 3 (200 cells/(L) and is HIV positive, is having AIDS-defining illness. A healthy client usually has at least 800 to 1000 CD4+ T-cells/mm 3 of blood. The CD4+ T-cells are reduced in the client with HIV disease. Client 1, with a CD4+ T-cell count of 750 cells/mm 3 and HIV positive, does not have AIDS. Client 2, with a CD4+ T-cell count of 550 cells/mm 3 and HIV positive, does not have AIDS. Client 4, having a CD4+ T-cell count of 450 cells/mm 3 and HIV positive does not have AIDS.
Which condition would the nurse suspect when a client, who underwent a physical examination two days ago, reports itching? Eczema Hypersensitivity Contact dermatitis Anaphylactic shock
A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.
Which reaction is an example of a type I hypersensitivity reaction? Anaphylaxis Serum sickness Contact dermatitis Blood transfusion reaction
An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A blood transfusion reaction is a type II cytotoxic reaction.
Which condition is a result of Clostridium botulinum? Upper respiratory tract infection Toxic shock syndrome Urinary tract infection Food poisoning with progressive muscle paralysis
Clostridium botulinum bacteria causes food poisoning with progressive muscle paralysis. Many viruses and bacteria can cause upper respiratory tract infection, but Clostridium is not one of them. Toxic shock syndrome is caused by the bacteria Staphylococcus aureus. Klebsiella-Enterobacter organisms most likely cause urinary tract infections.
Which term describes the practice of placing clients with the same infection in a semi-private room? Isolating Cohorting Colonizing Cross-referencing
Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.
Which medication would the nurse anticipate incorporating into the plan of care to treat the client bitten by a snake that belongs to the class of North American pit vipers? Diazepam Epinephrine Acetaminophen Crotalidae polyvalent immune fab (CroFab)
CroFab is used for treating a victim bitten by a North American pit viper as a part of hospital care. Diazepam is a muscle relaxant used for the treatment of black widow spider bite. Epinephrine is used as a nursing priority for bees and wasps sting. Acetaminophen is used for the treatment of fever related to scorpion bite.
The nurse understands which preparations use toxoids but not live viruses? Select all that apply. One, some, or all responses may be correct. Rotavirus vaccine Varicella virus vaccine Measles, mumps, and rubella virus vaccine Diphtheria, hepatitis B, pertussis (acellular), polio, and tetanus vaccine Diphtheria and tetanus toxoids and acellular pertussis vaccine
Diphtheria, hepatitis B, pertussis (acellular), polio, and tetanus vaccine consists of diphtheria and tetanus toxoids plus inactivated bacterial components of pertussis, inactive viral antigen of hepatitis B, and inactivated poliovirus vaccine. Diphtheria and tetanus toxoids and acellular pertussis vaccine is a preparation consisting of toxoids plus inactive bacterial and viral components of diphtheria and tetanus toxoids and acellular pertussis vaccine. Rotavirus vaccine, varicella virus vaccine, and measles, mumps, and rubella virus vaccine are preparations containing live viruses.
The nurse is reviewing the medical records of several clients. Which client has a condition that is an autoimmune disorder? Addison disease Cushing syndrome Hashimoto disease Sheehan syndrome
Hashimoto disease is an autoimmune disorder, wherein the immune system attacks the thyroid gland. Addison disease is caused by adrenal insufficiency. Cushing syndrome is caused by increased body levels of cortisol. Sheehan syndrome is hemorrhage-associated hypopituitarism after delivery of a child.
Which mediator of injury is involved in the client with pruritic lesions from an immunoglobulin E (IgE)-mediated hypersensitivity reaction? Histamine Cytokine Neutrophil Macrophage
Histamine is one of the mediators of injury involving IgE-mediated injury and potentially causes pruritus. Cytokines are the mediators of injury in delayed hypersensitivity reaction. Neutrophils are involved in immune complex-mediated hypersensitivity reactions. Macrophages in tissues are involved in cytotoxic reactions.
Which type of immunoglobulin is present in tears, saliva, and breast milk? IgE IgA IgG IgM Confident
IgA immunoglobulin is present in tears, saliva, and breast milk. IgE and IgG immunoglobulins are present in plasma and interstitial fluids. IgM immunoglobulin is present in plasma.
Which process would the IgD immunoglobulin found in human cord blood support? Manifestation of allergic reactions Protection of the body's mucous surfaces Differentiation of B-lymphocytes Provision of the primary immune response
IgD is present on the lymphocyte surface and found in human cord blood; this immunoglobulin differentiates B-lymphocytes. IgE causes symptoms of allergic reactions by adhering to mast cells and basophils. IgE also helps defend the body against parasitic infections. IgA lines the mucous membranes and protects body surfaces. IgM provides the primary immune response.
Which type of immunity is acquired through the transfer of colostrum from the mother to the child? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity
Natural passive immunity is acquired through the transfer of colostrum from the mother to the child. Natural active immunity is acquired when there is a natural contact with an antigen through a clinical infection. Artificial active immunity is acquired through immunization with an antigen. Artificial passive immunity is acquired by injecting serum from an immune human.
Which role would norepinephrine's mechanism of action perform in managing anaphylaxis? Norepinephrine blocks the effects of histamine. Norepinephrine inhibits the degranulation of mast cells. Norepinephrine functions as a peripheral vasoconstrictor. Norepinephrine rapidly stimulates alpha- and beta-adrenergic receptors.
Norepinephrine is a vasopressor that elevates the blood pressure and cardiac output in clients suffering from anaphylactic reactions. Diphenhydramine HCl blocks the effects of histamine on various organs. Corticosteroids such as dexamethasone prevent the degranulation of mast cells. Epinephrine works by rapidly stimulating alpha- and beta-adrenergic receptors.
Which vaccine would the nurse administer orally in children? MMR vaccine Rotavirus vaccine Live influenza vaccine Meningococcal conjugate vaccine (MCV4)
Rotavirus vaccines are generally administered orally because these live viruses should replicate in the gut of the infant. MMR vaccines are generally administered subcutaneously in the upper region of the arm. Live influenza vaccines are administered nasally. Meningococcal conjugate vaccines (MCV4) are administered intramuscularly in the deltoid region.
Which characteristic is common in clients with Sjögren syndrome (SS)? Dry eyes Muscle cramping Urinary tract infection Elevated blood pressure
SS is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands. Muscle cramping, urinary tract infection, and elevated blood pressure are not common characteristics of SS.
Which disorder does the image illustrate? Angioedema Oral candidiasis Systemic sclerosis Systemic lupus erythematosus
Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that causes major body organs and systems to fail. The image illustrates a 'butterfly' rash, which is a major skin manifestation of systemic lupus erythematosus. Angioedema is the diffuse swelling of the eyes and lips. In oral candidiasis, white plaque-like lesions appear on the tongue, palate, pharynx, and buccal mucosa. In systemic sclerosis, skin thickening is observed on the trunk, face, and extremities.
Which acute site-specific effect is associated with radiation therapy on the chest and lung? Cystitis Taste change Acute xerostomia Nausea and vomiting
Taste changes are an acute site-specific effect of radiation therapy on the chest and lungs. Cystitis is an acute site-specific effect of radiation therapy on the abdomen and pelvis. Acute xerostomia is an acute site-specific effect of radiation therapy on the head and neck. Nausea and vomiting is an acute site-specific effect of radiation therapy on the abdomen and pelvis.
Which virus can cause encephalitis in adults and children? Rubella virus Parvovirus Rotaviruses West Nile virus
The West Nile virus causes encephalitis. German measles is caused by the rubella virus. Gastroenteritis is caused by parvovirus. Rotaviruses also cause gastroenteritis.
The nurse is planning to administer a modified bacteria immunization to a preschool child. Which agent will be administered? A toxoid A vaccine An allergen An antitoxin
The microbes in the vaccine have been modified so they will not cause active infection but will still elicit an immune response. A toxoid is a modified toxin in which the poisonous properties have been destroyed but the toxin is still capable of producing antibodies. An allergen is a substance that causes an allergic reaction. An antitoxin is an antibody that is capable of neutralizing a specific toxin.
Which size of induration after a tuberculin test signifies a positive result in a 16-year-old client with no risk factors? Record your answer using a whole number. mm
The nurse would consider an induration of 15 mm (1.5 cm) a positive sign of tuberculin testing in a 16-year-old client.
Which group has the highest rate of meningococcal infection? Infants Toddlers Older adults Young adults
Those between the ages of 16 and 21 years, many of whom are young adults, are most at risk for meningococcal infection and are the main target group for vaccination. Infants and toddlers can contract meningococcal infection, but it is not as prevalent in these groups as in the young adult population. Older adults do not have a higher prevalence of meningococcal infection than young adults; however, individuals in this group who are immunocompromised may benefit from receiving the vaccination or boosters.
Which medication is a leukotriene modifier used to manage and prevent allergic rhinitis? Zileuton Ephedrine Scopolamine Cromolyn sodium
Zileuton is a leukotriene modifier used to manage and prevent allergic rhinitis. Ephedrine is an ingredient in decongestants used to treat allergic rhinitis. Scopolamine is an anticholinergic used to reduce secretions. Cromolyn sodium is a mast cell stabilizing medication used to prevent mast cell membranes from opening when an allergen binds to immunoglobulin E (IgE).
Which statement indicates the function of natural killer cells within the immune system? Secrete immunoglobulins in response to the presence of a specific antigen Exhibit heightened selectivity and destroy nonself cells, including virally infected cells Enhance immune activity through secretion of cytokines and lymphokines Attack nonselectively on nonself cells, especially mutated and malignant cells
Natural killer cells attack nonselectively on nonself cells, especially body cells that have undergone mutation and become malignant. Plasma cells secrete immunoglobulins in response to the presence of a specific antigen. Cytotoxic T cells attack selectively and destroy nonself cells, including virally infected cells. Helper T cells enhance immune activity through secretion of cytokines and lymphokines to control or limit specific immune responses.
Which action would the nurse implement when caring for a client reporting a recent bee sting presenting with localized redness, swelling, intense localized pain, and itching? Applying cold compresses to the affected area Ensuring the client keeps the skin clean and dry Monitoring for neurological and cardiac symptoms Advising the client to launder all clothes with bleach
A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse would apply cold compresses to the affected area to reduce the pain and edema at the sting site. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurological manifestations, which requires monitoring by the nurse. Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure the client bleaches his or her clothes to prevent the transmission of the infection.
Which activity by the community nurse is an illness prevention strategy? Encouraging the client to exercise daily Arranging an immunization program for chickenpox Teaching the community about stress management Teaching the client about maintaining a nutritious diet
An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain their present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.
Which instruction would the nurse provide a client with leukopenia secondary to chemotherapy? 'You should avoid exposure to the sun and use a sunscreen.' 'You should eat high-fiber foods and increase fluid intake.' 'You should avoid large crowds and people with infections.' 'You should consume iron supplements and erythropoietin.'
Leukopenia consists of low levels of white blood cells. A leukopenic client should avoid large crowds and people with infection because the client may contract an infection as a result of compromised immunity. The suggestion of avoiding exposure to the sun and using a sunscreen would be beneficial for a client with chemotherapy-induced skin changes. The suggestion of eating high-fiber foods and increasing fluid intake would be beneficial for a client with constipation after chemotherapy. Consuming iron supplements and erythropoietin would be required for a client who developed anemia after chemotherapy.
Which condition is an example of a type IV hypersensitivity reaction? Select all that apply. One, some, or all responses may be correct. Poison ivy allergic reaction Sarcoidosis Myasthenia gravis Rheumatoid arthritis (RA) Systemic lupus erythematosus (SLE)
Sarcoidosis and poison ivy reactions are examples of type IV hypersensitivity reactions. In type IV hypersensitivity, the inflammation results from a reaction of sensitized T cells with the antigen and the resultant activation of macrophages because of the release of lymphokines. Myasthenia gravis is an example of a type II or cytotoxic hypersensitivity reaction. RA and SLE are examples of type III immune complex-mediated reactions.
Which client would a nurse expect to develop IgE antibodies? A client with pollen allergy A client undergoing a poison ivy reaction A client with bacterial infection A client undergoing a blood transfusion
A client with a pollen allergy develops IgE antibodies that may result in an anaphylactic reaction. A client with poison ivy develops delayed hypersensitivity, which is mediated by T lymphocytes. A client with a bacterial infection develops IgG and IgM antibodies. A client undergoing blood transfusion may develop IgG and IgM type II hypersensitivity reactions.
Which antimicrobial medication acts on susceptible pathogens by inhibiting nucleic acid synthesis? Penicillin Actinomycin Erythromycin Cephalosporin
Actinomycin is an antimicrobial medication that acts on susceptible pathogens by inhibiting nucleic acid synthesis. Penicillin acts on susceptible pathogens by inhibiting cell wall synthesis. Erythromycin acts on susceptible pathogens by inhibiting biosynthesis and reproduction. Cephalosporin acts on susceptible pathogens by inhibiting cell wall synthesis.
Which type of cytokine is used to treat anemia secondary to chronic kidney disease? α-Interferon Interleukin-2 Interleukin-11 Erythropoietin
Cytokines are small proteins that signal cells. Erythropoietin is used to treat anemia related to chronic kidney disease. The failing kidneys are not able to produce erythropoietin to signal the bone marrow to produce red blood cells, resulting in anemia. α-Interferon is used to treat hairy cell leukemia or malignant melanoma. Interleukin-2 is used to treat metastatic renal carcinoma. Interleukin-11 is used to prevent thrombocytopenia after chemotherapy.
Which type of immunity will clients acquire through immunizations with live or killed vaccines? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity
Artificial active immunity is acquired through immunization with live or killed vaccines. Natural active immunity is acquired when there is natural contact with antigens through a clinical infection. Natural passive immunity is acquired through the transfer of colostrum from mother to child. Artificial passive immunity is acquired by injecting serum from an immune human.
A client's respiratory tract infection, which started with a common cold, has progressed to whooping cough. The client reports "coughing fits" lasting for several minutes. Which organism is responsible for the client's condition? Bacillus anthracis Bordetella pertussis Streptococcus pneumoniae Mycobacterium tuberculosis
Bordetella pertussis causes whooping cough. Pertussis is a respiratory tract infection beginning with the common cold and progresses to whooping cough. The client also develops coughing episodes lasting for several minutes. Inhalation anthrax is caused by Bacillus anthracis. Streptococcus pneumoniae may cause pneumonia. Mycobacterium tuberculosis infection leads to tuberculosis.
Which blood types can potentially be used for transfusion when a client has type A negative blood? Type O positive Type AB positive Type A or O negative Type A or AB negative
Both A and O negative blood are compatible with the client's blood. A negative is the same as the client's blood type and preferred; in an emergency, type O negative blood also may be given. Although type O blood may be used, it will have to be Rh-negative; Rh-positive blood is incompatible with the client's blood and will cause hemolysis. Type AB positive blood is incompatible with the client's blood and will cause hemolysis. Type A negative blood is compatible with the client's blood, but type AB negative is incompatible and will cause hemolysis.
Which malnourished condition may predispose a client to secondary immunodeficiency? Cachexia Cirrhosis Diabetes mellitus Hodgkin lymphoma
Cachexia is a nutrition disorder that may occur because of wasting of muscle mass and weight, resulting in a secondary immunodeficiency disorder. Cirrhosis, diabetes mellitus, and Hodgkin lymphoma also lead to secondary immunodeficiency disorder, but these are not malnutrition disorders.
Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct. Avoid eating from buffets. Obtain annual flu vaccinations. Perform regular hand hygiene. Stay away from crowded areas. Report a temperature greater than 100.5°F.
Clients who receive an organ transplant need to take immunosuppressant medications for the rest of their lives to prevent organ rejection. These medications put the client at increased risk for infection. The nurse would provide infection prevention teaching to the client after renal transplant, which would include instructions to avoid eating from buffets, get an annual flu vaccine, practice regular hand hygiene, and avoid crowded areas. Clients would also be instructed to report a temperature greater than 100.5°F to their health care provider as it could indicate infection or organ rejection and requires treatment.
Which leukocyte releases vasoactive amines during a client's allergic reaction? Neutrophil Monocyte Eosinophil Macrophage
Eosinophils release vasoactive amines during allergic reactions to limit the extent of an allergic reaction. Neutrophils are phagocytes, and numbers increase in inflammation and infection. Monocytes are involved in the destruction of bacteria and cellular debris. Macrophages are involved in nonspecific recognition of foreign protein and microorganisms.
Which bacteria colonies are commonly found in a client's large intestine? Escherichia coli Neisseria gonorrhoeae Staphylococcus aureus Haemophilus influenzae
Escherichia coli are bacteria that are part of the normal flora in the large intestine. Neisseria gonorrhoeae causes gonorrhea and pelvic inflammatory disease. Staphylococcus aureus secretes toxins that damage cells and causes skin infections, pneumonia, urinary tract infections, acute osteomyelitis, and toxic shock syndrome. Haemophilus influenzae causes nasopharyngitis, meningitis, and pneumonia.
Which influenza vaccine would the nurse administer via the intranasal route? Fluarix Fluvirin FluMist Fluzone
FluMist is given intranasally. Fluarix, Fluvirin, and Fluzone are influenza vaccines administered via the intramuscular route.
Which organ-specific autoimmune disorder would the nurse associate with a client's kidney? Graves disease Addison disease Goodpasture syndrome Guillain-Barré syndrome
Goodpasture syndrome is an autoimmune disorder associated with the client's kidney. Graves disease and Addison disease are autoimmune disorders associated with the endocrine system. Guillain-Barré syndrome is an autoimmune disorder associated with the central nervous system.
Which cytokine increases growth and maturation of myeloid stem cells? Interleukin-2 Thrombopoietin Granulocyte colony-stimulating factor Granulocyte-macrophage colony-stimulating factor
Granulocyte-macrophage colony-stimulating factor is a cytokine that increases growth and maturation of myeloid stem cells. Interleukin-2 is a cytokine that increases growth and differentiation of T lymphocytes. Thrombopoietin is a cytokine that increases growth and differentiation of platelets. Granulocyte colony-stimulating factor is a cytokine that increases numbers and maturity of neutrophils.
Which basic strategy would the nurse teach a health class to reduce the incidence of human immunodeficiency virus (HIV) transmission? Select all that apply. One, some, or all responses may be correct. Using condoms Using separate toilets Practicing sexual abstinence Preventing direct casual contacts Sterilizing the household utensils
HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. A client should use condoms to prevent contact between the vaginal mucous membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils.
Which antibody forms first, after exposure to an antigen? Immunoglobulin A (IgA) Immunoglobulin E (IgE) Immunoglobulin G (IgG) Immunoglobulin M (IgM)
IgM is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.
A child is administered a rotavirus vaccine. Which adverse medication effect would the nurse monitor for? Intussusception Encephalopathy Thrombocytopenia Guillain-Barré syndrome
In rare cases, rotavirus vaccine causes intussusception, a life-threatening form of bowel obstruction that occurs due to the bowel folding in on itself. The DTaP vaccine causes encephalopathy in rare cases. MMR vaccines induce thrombocytopenia in a few vaccinated clients. Meningococcal conjugate vaccines cause Guillain-Barré syndrome in some children.
Which conclusion would the nurse make about the client's response to an area of induration of 10 mm within 48 hours after an annual tuberculin purified protein derivative (PPD) test? The client has contracted clinical tuberculosis. The client has passive immunity to tuberculosis. The client has been exposed to the tubercle bacillus. The client has developed a resistance to the tubercle bacillus.
Induration measuring 10 mm or more in diameter is interpreted as significant; it does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure; infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies; a positive tuberculin purified protein derivative indicates the presence of antibodies, not how they were formed. Developing a resistance to the tubercle bacillus reaction indicates exposure, not resistance.
The nurse understands which vaccine is administered through the intranasal route? Rotavirus vaccine Influenza (live) vaccine Varicella virus vaccine Human papillomavirus vaccine
Influenza (live) vaccine is administered through the intranasal route. The rotavirus vaccine is administered orally. The varicella virus vaccine is given as a subcutaneous injection. The human papillomavirus vaccine is given as intramuscular injection.
Which symptom indicates that a client with inhalation anthrax is in the fulminant stage? Fever Dry cough Mediastinitis Mild chest pain
Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. This disease has two stages of illness, the prodromal stage and the fulminant stage. The symptom of the fulminant stage is mediastinitis. The symptoms of the prodromal stage are fever, dry cough, and mild chest pain.
Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? Urticaria Tachycardia Restlessness Laryngeal edema
Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, cutaneous signs of urticaria, tachycardia, and increasing restlessness, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.
Which organism is responsible for causing Lyme disease in clients? Phthirus pubis Sarcoptes scabiei Borrelia burgdorferi Pediculus humanus var. corporis
Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by ticks. Phthirus pubis causes pediculosis. Scabies is caused by Sarcoptes scabiei. Pediculus humanus var. corporis also causes pediculosis.
Which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? Refraining from consuming fatty foods Refraining from consuming frequent meals Refraining from consuming high-calorie foods Refraining from consuming high-protein foods
Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. The client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutritional status. High-calorie and high-protein foods are beneficial to clients with AIDS because they provide energy and build immunity.
Which leukocyte would the nurse include when teaching about antibody-mediated immunity? Select all that apply. One, some, or all responses may be correct. Monocyte Memory cell Helper T cell B-lymphocyte Cytotoxic T cell
Memory cells and B-lymphocytes are involved in antibody-mediated immunity. Monocytes are involved in inflammation. Helper T cells and cytotoxic T cells are involved in cell-mediated immunity.
Which organ is protected by microglial cells? Lung Liver Brain Kidney
Microglial cells are macrophages present in the brain. The lungs are protected by alveolar macrophages. The liver is protected by Kupffer cells. Mesangial cells are present in the kidneys.
Which statements regarding the adverse effects of immunization are true? Select all that apply. One, some, or all responses may be correct. Only diphtheria vaccines cause acute encephalopathy. Oral poliovirus vaccine causes paralytic poliomyelitis. Hepatitis B vaccine is the safest vaccine because it does not cause adverse side effects. Swelling of glands in the cheeks and neck is an adverse effect of the measles vaccine. Fever and erythema at the injection site are common adverse effects of all vaccines.
Paralytic poliomyelitis is caused only by the poliovirus vaccine; it occurs when the live vaccine undergoes mutation in the intestine and enters the central nervous system. The swelling of glands in the cheeks and neck is a mild adverse effect of the measles vaccine. Almost all vaccines cause fever and erythema at the injection site; these effects are the result of activation of the body's defense mechanism. Acute encephalopathy is a serious side effect of not only the diphtheria vaccine but also the tetanus toxoid and acellular pertussis vaccine. Hepatitis B, with only mild side effects, is one of the safest vaccines.
Which late effect of radiation therapy on the heart would the nurse monitor as a priority on a client? Trismus Pericarditis Lymphedema Pulmonary fibrosis
Pericarditis is a late effect of radiation therapy on the heart. Trismus is a late effect of radiation therapy on the head and neck. Lymphedema is a late effect of radiation therapy on the chest wall of the client. Pulmonary fibrosis is a late effect of radiation therapy on the lungs of the client.
The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care? Easing pain Minimizing scarring Preventing infection Avoiding skin breakdown
Pin sites provide a direct avenue for organisms into the bone. Pin site care is priority over easing pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.
Which area of the body would the nurse explain is affected by pituitary and hypothalamic dysfunction because of the effects of radiation therapy? Lungs Head Abdomen Central nervous system
Pituitary and hypothalamic dysfunction are late effects of radiation therapy involving the central nervous system. Pulmonary fibrosis is a late effect of radiation on the lungs. Osteoradionecrosis is a late effect of radiation on the head and neck. Small and large bowel injury are late effects of radiation on the abdomen and the pelvis.
Which rationale supports administering the medication pregabalin to a client with acquired immunodeficiency syndrome (AIDS)? To reduce neuropathic pain To reduce emotional changes To reduce swallowing difficulty To reduce muscle and joint pain
Pregabalin is indicated for neuropathic pain based on its mechanism of interference with nerve signaling. Clients with AIDS generally exhibit emotional and behavioral changes, which can be managed with appropriate antidepressants and anxiolytics. AIDS clients who experience difficulty swallowing may have candidal esophagitis; this condition can be managed with antifungal mediations such as fluconazole or amphotericin B. Traditional analgesics are used to manage joint and muscle pain.
The nurse providing primary preventive care at a community health care center focuses on which type of activity? Rehabilitating the client Treating early stages of disease Preventing complications from illness Promoting health in healthy individuals
Primary prevention precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Health education programs, immunizations, and physical and nutritional fitness activities are primary prevention activities. Tertiary preventive care occurs when an individual has a permanent or irreversible disability. The client undergoing rehabilitation is receiving tertiary preventive care. Secondary preventive care focuses on individuals who are experiencing health problems. Secondary preventive care involves treating clients in the early stages of disease. It also focuses on preventing complications from illness.
Which type of hypersensitivity reaction would the nurse teach a client with rheumatoid arthritis (RA)? Delayed Cytotoxic Immunoglobulin E (IgE)-mediated Immune complex
RA is an autoimmune disorder associated with an immune-complex type of hypersensitivity reaction. Contact dermatitis caused by poison ivy is associated with a delayed type of hypersensitivity reaction. Goodpasture syndrome is associated with a cytotoxic type of hypersensitivity reaction. Asthma is associated with an IgE-mediated type of hypersensitivity reaction.
Which identified clinical manifestation is a sign of allergic rhinitis? Presence of high-grade fever Reduced breathing through the mouth Presence of pinkish nasal discharge Reduced transillumination on the skin over the sinuses
Reduced transillumination on the skin overlying the sinuses indicates allergic rhinitis. This effect is caused by the sinuses becoming inflamed and blocked with thick mucoid secretions. Generally, fever does not accompany allergic rhinitis unless the client develops a secondary infection. In allergic rhinitis, the client is unable to breathe through the nose because it gets stuffy and blocked. Instead, the client will resort to mouth breathing. Clients with allergic rhinitis will have clear or white nasal discharge.
Which type of rehabilitation is an essential component to a client's recovery from Guillain-Barré syndrome? Physical therapy Speech exercises Fitting with a vertebral brace Follow-up on cataract progression
Rehabilitation needs for a client with Guillain-Barre syndrome focuses on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome.
An Rh-negative client has a spontaneous abortion at the end of the second trimester and is prescribed Rho(D) immune globulin. The client asks the nurse, "Why do I need this medication?" Which information would the nurse consider before answering the client's question? It will expand the woman's antibody pool. It will prevent the woman from producing antibodies. The woman's production of immune bodies will be accelerated. The activity of the mother's Rh-negative antibodies will be suppressed.
Rho(D) immune globulin attacks fetal red cells that have gained access to the maternal bloodstream at the time of birth; it prevents antibody formation. Antibody formation is undesirable; it sensitizes the woman and contributes to fetal red cell destruction in future pregnancies. There is no production of immune bodies. Rho(D) immune globulin prevents the woman's immune system from responding to the fetal Rh-positive blood.
The nurse understands which vaccine may cause intussusception in children? Rotavirus Hepatitis Measles, mumps, and rubella Diphtheria, tetanus, and pertussis
Rotavirus vaccines very rarely cause intussusception, a form of bowel obstruction in which the bowel telescopes in on itself. Hepatitis vaccines can cause anaphylactic reactions. The measles, mumps, and rubella vaccine may cause thrombocytopenia. The diphtheria, tetanus, and pertussis vaccine carries a small risk of causing acute encephalopathy, convulsions, and a shock-like state.
Which type of hypersensitivity reaction is associated with systemic lupus erythematosus (SLE)? Type I Type II Type III Type IV
SLE is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I, or immediate hypersensitive reaction. Cytotoxic, or type II, hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions caused by delayed, or type IV, hypersensitivity reactions.
Which role does shark cartilage play in the management of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)? Shark cartilage enhances immunity. Shark cartilage reduces oral thrush. Shark cartilage is a complementary therapy. Shark cartilage is a nutritional supplement.
Shark cartilage is considered an alternative or complementary therapy to prescribed medications for clients with HIV and AIDS. Lymphocyte transfusions and bone marrow transplants are used to improve immunity in clients with HIV and AIDS. Lemon juice and lemongrass may provide relief from oral thrush in some clients with HIV and AIDS. A high-calorie, high-protein diet is advised to clients with HIV and AIDS to improve their nutritional status.
Which action would the nurse implement when providing care for a client with acquired immunodeficiency syndrome (AIDS)? Use standard precautions. Employ airborne precautions. Plan interventions to limit direct contact. Discourage long visits from family members.
The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states that standard precautions should be used for all clients; these precautions include wearing of gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact or discouraging long visits from family members will unnecessarily isolate the client.
Which statement describes the function of IgG antibodies in the body? Activates the degranulation of mast cells Activates the classic complement pathway Prevents upper respiratory tract infections Prevents lower respiratory tract infections
The classic complement pathway is activated by the IgG and IgM antibodies. IgE antibodies cause a degranulation of mast cells. IgA antibodies are found largely in mucous membrane secretions and play an important role in preventing upper and lower respiratory tract infections.
Which type of delayed hypersensitivity reaction does the client pictured in the image likely have? Type I Type II Type III Type IV
The client is having contact dermatitis of the skin to rubber boots. This image presents a clinical example of a delayed hypersensitivity reaction, a type IV reaction. This reaction is also known as a cell-mediated immune response. Anaphylactic reactions are type I reactions that occur only in susceptible people who are highly sensitized to specific allergens. Hemolytic transfusion reactions are type II reactions that occur when a recipient receives ABO-incompatible blood from a donor. Tissue damage will occur in type III reactions, which are immune-complex reactions usually occurring secondary to antigen-antibody complexes.
Which important reason accounts for why medications used to treat acquired immunodeficiency syndrome (AIDS) become ineffective? Taking the medications 90% of the time Missing doses of the prescribed medications Taking medications from different classifications Developing immune reconstitution inflammatory syndrome (IRIS)
The most important reason for the development of medication resistance in the treatment of AIDS is missing doses of medications. When doses are missed, the blood medication concentrations become lower than what is needed to inhibit viral replication. The virus replicates and produces new particles that are resistant to the medications. Taking the medications 90% of the time prevents medications from becoming ineffective. Taking medications from different classes prevents the medications from becoming ineffective. IRIS occurs when T cells rebound with medication therapy and become aware of opportunistic infections.
The mother of a child with acute poststreptococcal glomerulonephritis (APSGN) is concerned that a younger sibling may also have the disorder. What does the nurse recall when preparing to explain the cause of the disease process? A systemic infection causing clots in the small renal tubules A factor that is unknown and is difficult to prevent An immune complex disorder occurring after a group A β-hemolytic Streptococcus infection An autosomal recessive trait, meaning that there is an increased probability that a sibling will also have the disease
The β-hemolytic Streptococcus immune complex becomes trapped in the glomerular capillary loop, causing APSGN. APSGN is usually precipitated by a localized pharyngitis. Clots do not form in the small renal tubules with APSGN. Prevention depends on treating an individual with a group A β-hemolytic Streptococcus infection with antibiotics to eliminate the organism before an immune response can occur. APSGN is an acquired, not an inherited, disorder.
Which type of vaccines triggers the recipient's immune system to produce antitoxins? Live vaccines Killed vaccines Toxoid vaccines Specific immune globulins
Toxoids are a nontoxic form of bacterial toxins that induce the formation of antitoxins by the recipient's immune system. Examples of these types of vaccines include tetanus toxoid and diphtheria toxoid. Both live and killed vaccines induce the body's immune system to produce antibodies, making the individual actively immune to the microbes. Specific immune globulins are high concentration of antibodies prepared from donated blood directed against specific antigens.
Which medication reduces the risk for human immunodeficiency virus (HIV) infection in unaffected individuals? Truvada Abacavir Cromolyn Methdilazine
Truvada is the first medication approved to reduce the risk for HIV infection in unaffected individuals who are at a high risk of HIV infection. Abacavir treats HIV infection and is a reverse transcriptase inhibitor. Cromolyn manages allergic rhinitis and asthma. Methdilazine, an antihistamine, treat the skin and provides relief from itching.
Which medication treats hay fever by preventing leukotriene synthesis? Zileuton Cromolyn sodium Chlorpheniramine Diphenhydramine
Zileuton is a leukotriene antagonist medication; this substance prevents the synthesis of leukotrienes and helps in managing and preventing hay fever. Cromolyn sodium stabilizes mast cells and prevents the opening of mast cell membranes in response to allergens binding to immunoglobulin E. Chlorpheniramine and diphenhydramine are antihistamines and prevent the binding of histamine to receptor cells and decrease allergic manifestations.
Which cytokine would the nurse teach a client is treatment for multiple sclerosis? β-Interferon Interleukin-2 Erythropoietin Colony-stimulating factor
β-Interferon is a cytokine used to treat multiple sclerosis. Interleukin-2 is used to treat metastatic melanoma. Erythropoietin is a cytokine used to treat anemia related to chemotherapy. Colony-stimulating factor is a cytokine used to treat chemotherapy-induced neutropenia.
