NU271 PrepU: Disorders of the Immune Response (week 9)

A client describes himself as being "devastated" after hearing that his HIV test has come back positive. Which response by the nurse is most appropriate?

"It's entirely normal to feel that way. We are going to try our best to help you get all the support you need." - The nurse's best response is to validate the client's statement and to affirm a commitment to support him. It is presumptuous to conclude that by saying he is "devastated" he means that he is ashamed or afraid. Similarly, it is presumptuous for the nurse to claim that he or she knows how the client is feeling.

The treatment of HIV/AIDS is complicated because different drugs act on different stages of the replication cycle of the virus. Therefore, treatment includes combinations of two, three, or more drugs. What is this treatment called?

HAART treatment - Because different drugs act on different stages of the replication cycle, optimal treatment includes a combination of at least two to three drugs, often referred to as HAART [highly active antiretroviral therapy]. The goal of HAART is sustained suppression of HIV replication, resulting in an undetectable viral load and an increasing CD4+ cell count. The other treatments are not used in the treatment of HIV/AIDS.

An 8-week-old boy has been recently diagnosed with a severe combined immunodeficiency (SCID). His parents have performed a significant amount of research on the Internet and have brought a large amount of material to discuss with their care provider. Which statement best reflects an accurate understanding of their son's health situation?

"Our son likely has a deficiency of B-lymphocytes and can't produce antibodies." - The pathophysiology of SCID involves normal B cells but also a lack of antibody production because of inadequate T cell help. Gene therapy is not yet a realistic treatment option, and the disease has a genetic basis. Antibodies are not incorrect, but rather inadequate in number.

HIV is considered to be a retrovirus because:

it carries its genetic information in ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). - Like other retroviruses, HIV carries its genetic information in ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). In the process of taking over the CD4+ T cell, the virus attaches to receptors on the CD4+ cell, fuses to and enters the cell, incorporates its RNA into the cell's DNA, and then uses the CD4+ cell's DNA to reproduce large amounts of HIV, which are released into the blood.

Manifestations of Kaposi sarcoma include:

lesions of the skin and in the oral cavity, gastrointestinal tract, and lungs. - Kaposi sarcoma is a malignancy of the endothelial cells that line small blood vessels through out the body. The lesions of Kaposi sarcoma can be found on the skin and in the oral cavity, gastrointestinal tract, and the lungs. The other symptoms may appear in clients who have AIDS, but for different reasons than having Kaposi sarcoma.

A parent brings a 6-month-old infant to the primary care physician to treat the infant's third respiratory infection since birth. What explanation will the nurse give for the order to administer intravenous immunoglobulin (IVIg)?

"IVIg supplements the infant's immunity to prevent recurrent infection." - Transient hypogammaglobulinemia is a condition that occurs when one or more of the serum Ig levels is reduced. Symptoms usually appear when the maternal IgG antibody levels decline during the first 6 months of life and the infant's immune system is unable to synthesize adequate Ig on its own. The most frequent manifestations include upper and lower respiratory tract infections, allergies, and allergic asthma. Treatment includes antibiotics and intravenous immunoglobulin (IVIg) to stop the cycle of infection. Most cases resolve spontaneously by age 3 years.

A client develops an immunodeficiency disorder after receiving chemotherapy for the treatment of lung cancer. The client asks the nurse if he was born with this deficiency. What is the nurse's best response?

"You have developed a secondary immunodeficiency disorder as a result of your chemotherapy." - Secondary immunodeficiency disorders develop later in life as a result of other pathophysiologic states such as malnutrition, disseminated cancers; infection of the cells of the immune system, most notably with human immunodeficiency virus, and treatment with immunosuppressant drugs, such as chemotherapeutic agents, corticosteroids, or transplant rejection medications.

Shortly after being diagnosed with HIV, a client has begun highly active antiretroviral therapy (HAART). The client asks, "My doctor tells me that my viral load is going down. What does that mean?" The nurse's best response is:

"Your HAART medications are working to slow the progression of the disease." - Antiviral therapies such as HAART are prescribed to slow the progression of AIDS and improve the overall quality of life and survival time of persons with HIV infection. Extension, not limitation, of the latent period is a goal. Minimizing transmission and preventing seroconversion are not normally achievable goals through drug therapy alone. The final 5% to 15% are long-term nonprogressors, who remain asymptomatic for 10 years or more after seroconversion, with stable CD4+ T-cell counts and low plasma HIV RNA levels.

The nurse is teaching health promotion related to HIV-infection prevention. What should be discussed in the teaching? Select all that apply.

Abstinence and long-term mutual monogamous sexual relationship between two uninfected people as the best ways to prevent HIV infection, Abstinence and long-term mutual monogamous sexual relationship between two uninfected people as the best ways to prevent HIV infection, The use of household bleach mixture to disinfect syringes used by illicit drug users, Routine screening of all people between the ages of 13 and 64 - Because there is no cure for HIV infection or AIDS, adopting risk-free or low-risk behavior is the best protection against the disease. Abstinence and long-term, mutually monogamous sexual relationships between two uninfected partners are the best ways to avoid HIV infection. Correct and consistent use of latex condoms can provide protection. Only water-base lubricants should be used with condoms. People who choose to inject drugs should use a sterile syringe for each injection or, if this is not possible, clean their syringes with a household bleach mixture. The CDC recommends that all people between 13 and 64 years of age should be routinely screened for HIV.

An infant is suspected of having a severe primary immunodeficiency disease. Which effect on the infant makes early detection a priority?

Administering live attenuated virus vaccines can be fatal. - For infants born with severe primary immunodeficiency diseases combined T- and B-cell immunodeficiency, early diagnosis is essential before the development of severe infections and the administration of live attenuated virus vaccines (e.g., measles, mumps, rubella, varicella, and bacillus Calumet-Guerin), which could have devastating and life-threatening complications. The infant may have developmental delays but these delays are not a priority related to this diagnosis. The infant is not at risk for cardiovascular disease any more so than other children of this age group.

A dental assistant comes to the clinic with reports of a rash on her hands that feel like they are coming from the gloves being worn. The nurse observes both hands with crusted and thickened areas. What type of education does the nurse anticipate providing to the client?

Apply a topical corticosteroid and avoid further contact with latex-containing products. - Type IV hypersensitivity reactions to latex gloves are the most common form of latex allergy seen. In this form of allergy, people usually develop a contact dermatitis to one of the chemical additives rather than the latex proteins within 48 to 96 hours of exposure. The contact dermatitis often affects the dorsum of the hands and is characterized by a vesicular, pruritic rash. When glove contact is continued, the area becomes crusted and thickened. Treatment is with topical corticosteroids during the acute phase and avoidance of all latex-containing products.

Physical changes associated with lipodystrophy related to HIV infection include which manifestations? Select all that apply.

Buffalo hump, Breast enlargement, Increased abdominal girth - The alterations in body appearance associated with lipodystrophy include an increase in abdominal girth, buffalo hump development, wasting of fat from the face and extremities, and breast enlargement in men and women.

The nurse is caring for a client who is HIV positive and is newly diagnosed with Mycobacterium tuberculosis (TB). Which manifestations does the nurse associate with TB? Select all that apply.

Cough, Fever, Night sweats - Most people who have TB present with fever, night sweats, cough, and weight loss. Rash is not a symptom.

The nurse is obtaining an admission assessment of a client. Which disease history would the nurse document as a secondary disorder of phagocytosis, an autoimmune disease?

Diabetes mellitus - Probable autoimmune diseases include mixed connective tissue disease, polymyositis-dermatomyositis, rheumatoid arthritis, scleroderma, Sjogren syndrome, systemic lupus erythematosus, autoimmune hemolytic anemia, autoimmune neutropenia and lymphopenia, idiopathic thrombocytopenic purpura, acute idiopathic polyneuritis, atrophic gastritis and pernicious anemia, autoimmune adrenalitis, Goodpasture syndrome, Hashimoto thyroiditis, type 1 diabetes mellitus, myasthenia gravis, premature gonadal (ovarian) failure, primary biliary cirrhosis, sympathetic ophthalmia, temporal arteritis, thyrotoxicosis (Graves disease), Crohn disease, and ulcerative colitis.

The school nurse is preparing a lecture on the human immunodeficiency virus (HIV) for high school students. The nurse includes which information about the transmission of HIV? Select all that apply.

HIV is transmitted through blood-to-blood contact., HIV is transmitted from the mother to the unborn baby., HIV is transmitted through sexual contact. - HIV is transmitted from one person to another through sexual contact, blood-to-blood contact, or perinatally. It is not transmitted through casual contact. Several studies involving more than 1,000 uninfected, nonsexual household contacts with persons with HIV infection (including siblings, parents, and children) have shown no evidence of casual transmission. HIV is not spread by mosquitoes or other insect vectors.

The school nurse is preparing a lecture on the human immunodeficiency virus (HIV) for high school students. The nurse includes which information about the transmission of HIV? Select all that apply.

HIV is transmitted through sexual contact., HIV is transmitted through blood-to-blood contact., HIV is transmitted from the mother to the unborn baby. - HIV is transmitted from one person to another through sexual contact, blood-to-blood contact, or perinatally. It is not transmitted through casual contact. Several studies involving more than 1,000 uninfected, nonsexual household contacts with persons with HIV infection (including siblings, parents, and children) have shown no evidence of casual transmission. HIV is not spread by mosquitoes or other insect vectors.

A 48-year-old man who has been HIV positive for 6 years has just learned that he has been diagnosed with Kaposi sarcoma (KS). Which fact most accurately conveys an aspect of his diagnosis?

He is likely to have lesions on his skin, mouth, or GI tract. - The lesions of KS can be found on the skin and in the oral cavity, gastrointestinal tract, and the lungs. More than 50% of people with skin lesions also have gastrointestinal lesions. It is linked with a herpes virus and can often be painless, especially in early stages. Men who have sex with men are at a higher risk of developing KS.

A client is suffering from the effects of the opportunistic infection, Cryptosporidium parvum. An important nursing intervention would be to encourage which action?

Hydration - Cryptosporidium parvum has clinical features ranging from mild diarrhea to severe, watery diarrhea with a loss of up to several liters per day. Hydration is an important consideration.

While undergoing a kidney transplant from a non-family member, the client's transplanted kidney has just had the arterial clamps removed. The OR staff notices that the organ is turning purple with no urine output. When explaining to the family why they had to remove the donor kidney, the nurse will anticipate that the surgeon would likely include which statement?

Hyperacute rejection occurs because antibodies against HLA antigens are deposited in vessels, causing necrosis. - Antibody-mediated rejection can be hyperacute, which occurs almost immediately after vascular reperfusion to graft tissue occurs. Performed antibodies against HLA antigens are deposited in the tissue endothelium and microvasculature where they activate the classic complement pathway, causing tissue necrosis and graft injury.

A client with common variable immunodeficiency (CVID) is admitted to the hospital for treatment. Which type of treatment will the nurse be administering to the client?

IV immunoglobulin - Treatment methods for CVID are similar to those used for other primary humoral immunodeficiencies, with IVIg being the mainstay of therapy.

In a newborn, which antibody crosses the placenta to provide protection from infection?

IgG - IgG antibodies cross the placenta to provide protection from infection. The other antibodies (IgA, IgM, IgD, and IgE) are normally deficient and do not normally cross the placenta.

The nurse is teaching a new mother about caring for her baby and reducing the risk for infection. On what principle does the nurse base the knowledge of passive immunity?

Infants are protected at birth from infection by maternal IgG. - At birth, infants are protected from infection my maternal IgG antibodies that have crossed the placenta during fetal development. Infants are normally deficient in IgA, IgM, IgD, and IgE because immunoglobulins do not normally cross the placenta.

Type III hypersensitivity immune responses can be harmful when immune complex deposits in tissue cause which type of damage to tissues?

Inflammation - Type III responses create immune complexes that are deposited in the affected tissues, activating an inflammatory response. Autoantibodies are involved with type II responses; cytotoxic cells are involved with type II and type IV responses. Immunoglobulins are released in response to B-cell activation of plasma cells, which does not occur as part of type III reactions.

A client diagnosed with the autoimmune disorder Hashimoto's thyroiditis asks the nurse what he has done to cause this disorder. What knowledge by the nurse should the response be based upon?

It is a result of the loss of immunologic self-tolerance. - Autoimmune disorders are caused by a loss of immunologic self-tolerance, which results in damage to body tissues. Autoimmune diseases are a heterogenous group of disorders and dependent upon the target of the autoreactive lymphocytes. Breakdown in T-cell anergy is a state of reduced function, in which an immunocompetent, antigen-specific T cell is unable to respond to an appropriate stimulus and does not result in an autoimmune response. Molecular mimicry is a theory that has been postulated to describe the mechanisms by which infectious agents or other foreign substances trigger an immune response against autoantigens.

Which is a characteristic finding in AIDS?

Kaposi sarcoma - People with AIDS have a high incidence of certain malignancies, especially Kaposi sarcoma, a malignancy of the endothelial cells that line small blood vessels throughout the body.

Cryptosporidium parvum has clinical features ranging from mild diarrhea to severe, watery diarrhea with a loss of up to several liters per day. Hydration is an important consideration.

Molecular mimicry - Molecular mimicry is one theory that has been postulated to describe the mechanisms by which infectious agents or other foreign substances trigger an immune response against autoantigens. Superantigens are a family of related substances, including staphylococcal and streptococcal exotoxins, that induce uncontrolled proliferation and activation of T lymphocytes, causing fever, shock, and death. Release of sequestered antigens may cause posttraumatic uveitis and orchiditis after systemic release of spermatozoa and ocular antigens. Anergy is a state of reduced function, in which an immunocompetent, antigen-specific T cell is unable to respond to an appropriate stimulus.

A 37-year-old male with HIV who has recently become symptomatic has begun highly active antiretroviral therapy (HAART). Among the numerous medications that he now regularly takes are several that inhibit the change of HIV RNA to DNA in a CD4+ cell. Which class of medications addresses this component of the HIV replication cycle?

Non-nucleoside reverse transcriptase inhibitors - Reverse transcriptase inhibitors inhibit HIV replication by acting on the enzyme reverse transcriptase. Non-nucleotide reverse transcriptase inhibitors block the copying of RNA into DNA. Entry inhibitors, protease inhibitors and integrase inhibitors do not address this aspect of the HIV replication cycle.

The primary health care provider prescribes new medications to treat a client with an autoimmune disorder. Which order would the nurse question?

Spironolactone - Autoimmune disorders occur when the immune system attacks the body tissues. Treatments include the use of corticosteroids to suppress the immune response, plasmapheresis to remove circulating autoreactive cells, and targeted therapies such as the monoclonal antibody, belimumab. Monoclonal antibodies may reduce the autoimmune response by blocking B-cell activity, inhibiting B-cell growth factors, or interfering with B-cell communication with T cells. The potassium-sparing diuretic spironolactone would not be effective in treating an autoimmune disorder.

An infant has been born to a client who is HIV positive. What is the infant's most likely prognosis for developing AIDS?

The infant can be HIV antibody positive by ELISA for up to 18 months of age without being actively infected with HIV. - Infants born to HIV-infected women can be HIV antibody positive by ELISA for up to 18 months of age even though they are not infected with HIV. PCR testing for HIV DNA is used most often to diagnose HIV infection in infants younger than 18 months of age. Two positive PCR tests for HIV DNA are needed to diagnose a child with HIV infection. Children born to mothers with HIV infection are considered uninfected if they become HIV antibody negative after 6 months of age, have no other laboratory evidence of HIV infection, and have not met the surveillance-case-definition criteria for AIDS in children. It is possible for them to develop AIDS. Passive immunity is not likely to eradicate the virus.

The type of hypersensitivity reaction that is mediated by IgG or IgM antibodies directed against target antigens on specific host cell surfaces or tissues is also known as which type of hypersensitivity reaction?

Type II - A type I hypersensitivity reaction is dependent on IgE-mediated activation of mast cells and basophils and the subsequent release of chemical mediators of the inflammatory response. Type II hypersensitivity reactions are mediated by IgG or IgM antibodies directed against target antigens on specific host cell surfaces or tissues and result in complement mediated phagocytosis and cellular injury. Type III hypersensitivity is caused by the formation of antigen-antibody immune complexes in the bloodstream, which are subsequently deposited in vascular epithelium or extravascular tissues and which activate the complement system and induce a massive inflammatory response. Type IV hypersensitivity involves tissue damage in which cell-mediated immune responses with sensitized T lymphocytes cause cell and tissue injury.

The nurse is caring for a client with common variable immunodeficiency (CVID) disorder. Which clinical manifestation of the disorder is common with this client?

Viral pneumonia - Clinical manifestations of CVID can begin at any time of life and most commonly include recurrent bacterial and viral infections of the respiratory tract.

A 67-year-old client diagnosed with myasthenia gravis will likely display which clinical manifestations as a result of autoantibodies ultimately blocking the action of acetylcholine, resulting in destruction of the receptors?

Weakness of the eye muscles, difficulty in swallowing and slurred speech, impaired gait. - Myasthenia gravis ultimately results in destruction of receptors in the neuromuscular junction, leading to a decrease in neuromuscular function. Tremor of hands/arms, rigidity of the arms, and shuffling gait are signs/symptoms of Parkinson's disease. Short-term memory lapses, problems with orientation, and a lack of drive or initiative are signs/symptoms of Huntington disease. Facial droop, slurred speech, and weakness on one side of the body are classic signs/symptoms of CVA.

When counseling a male client with suspected HIV, the nurse informs him that if the enzyme-linked immunosorbent assay (ELISA) comes back positive, then:

a second test known as the Western blot assay will be ordered to confirm positive HIV status. - If ELISA positive, then sent for Western blot assay. If Western blot is positive, diagnosis of HIV confirmed. If Western blot is negative, then the person is NOT infected with HIV.

Which client would be diagnosed with wasting syndrome?

client with AIDS, fever, diarrhea, and significant involuntary weight loss - A client diagnosed with wasting syndrome (an AIDS-defining illness) would have chronic fever, diarrhea, and a significant involuntary weight loss (usually more than 10%) without an opportunistic infection. Pneumonia, Kaposi sarcoma, and herpes simplex and candidiasis are all opportunistic infection.