Nursing Assessment: Immune Function

A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used?

Digestive enzymes destroy its protein structure.

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?

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

Which of the following cell types are involved in humoral immunity?

B lymphocytes

An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response?

B lymphocytes produce antibodies that are specific to the pathogen.

During an allergic reaction, histamine is released in about 15 minutes. The patient usually takes an antihistamine that has an affinity for bronchiolar smooth muscle cells (an H2 receptor). Which of the following is most likely the drug described?

Benadryl

The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?

Lymphoid tissues

Which is an action of cytotoxic T cells?

Lyse cells infected with virus

Which condition is associated with impaired immunity relating to the aging client?

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.

A patient with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. What is the immune response that predominates in this situation?

Cellular

The nurse is caring for a client with myasthenia gravis. The nurse generates a plan of care for the client based on which type of hypersensitivity reaction?

Cytotoxic

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

Cytotoxic T cell

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated?

Cytotoxic T cells

Which of the following protective responses begin with the B lymphocytes?

Humoral

When the body is in contact with an allergen, this lymphocyte, located in the respiratory and intestinal mucosa, triggers the release of histamine. Choose that lymphocyte.

Ig E

A 6-year-old client is diagnosed with a viral infection of the respiratory system. Which will most likely be trying to fight the antigen?

Interferons

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 immunoglobulins

Which allergic reaction is potentially life threatening?

angioedema

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

infectious cells foreign cells cancerous cells

A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

"If I notice tingling in my lips or mouth, gargling may help the symptoms."

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."

A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of his last tetanus shot, which he tells the nurse was more than 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what?

An antibody

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

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?

Assure the client that this is a normal reaction

A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which reason?

Exposure to foreign antigens may cause altered immune function.

A woman who has experienced severe seasonal allergies in recent years has been referred for allergy skin testing. The nurse at the allergy clinic should be aware of the need to take precautions against the patient's risk of which of the following nursing diagnoses?

Impaired gas exchange

A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact her bone marrow is unable to produce a sufficient amount of what?

Lymphocytes

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Natural killer cells

Which type of immunity becomes active as a result of infection by a specific microorganism?

Naturally acquired active immunity

The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function?

Previous organ transplantation

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells

In the immune response cycle, lymphocytes interfere with disease by picking up specific antigens from organisms to alter their function during which stage of an immune response?

Proliferation

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?

Surgical removal of the appendix

A client is 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 ensures a written consent is obtained prior to testing.

A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection?

Through the mucous membranes of the throat

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen.

The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication?

interferons

Which immunity type becomes active as a result of infection by a specific microorganism?

naturally acquired active immunity

A client presents with itching, swelling, redness, and wheals of superficial skin layers. What is the most likely type of allergy this client is displaying?

urticaria

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