115 PrepU Chapter 31: Assessment of Immune Function

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?

Ataxia

A child is brought to the clinic with a rash and is subsequently diagnosed with measles. The parent reports also having had measles as a young child. What type of immunity to measles develops after the initial infection?

Naturally acquired active immunity

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

Naturally acquired active immunity

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

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells.

The nurse is caring for a client with a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?

Protein electrophoresis

In which response do T lymphocytes have a role?

Transplant rejection

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

infectious cells foreign cells cancerous cells

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?"

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

B lymphocytes

The nurse is obtaining the medical history of a client with Crohn's disease. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?

Corticosteroids

A patient who suffered severe partial thickness burns to the face and trunk is at risk for depletion of essential proteins and immunoglobulins. The stressors associated with this patient's major injury have caused what immune process to occur?

Cortisol is released from the adrenal cortex, which contributes to immunosuppression.

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

Cytotoxic T cell

Which of the following is a age-related change associated with the immune system?

Decreased antibody production

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

Humoral

Which immunoglobulin assumes a major role in bloodborne and tissue infections?

IgG

Which of the following is a center for immune cell proliferation?

Lymph node

A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?

Natural immunity

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

naturally acquired active immunity

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:

neutrophils and monocytes.

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 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

A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response?

"It is a hyperimmune response to something in the environment that is usually harmless."

A client with an autoimmune disorder asks, "Why is autoimmune disease more prevalent in the women in my family?" Which response will the nurse make to this client?

"It's believed to be caused by the differences in the sex hormones."

A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?

Administer epinephrine.

Which of the following is accurate regarding acquired immunity?

An immunologic response acquired during life but not present at birth Usually develops as a result of exposure to an antigen through immunization Can develop by contracting a disease

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

Artificially acquired active immunity

A client is diagnosed with rheumatoid arthritis. When teaching the client and family about rheumatoid arthritis, the nurse should provide which information?

Autoimmune disorders include connective tissue (collagen) disorders.

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?

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

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

A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:

Lymphocytes migrate to areas of the lymph node

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

Natural killer cells

Which type of cell is capable of directly killing invading organisms and producing cytokines?

Natural killer cells

A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles?

Phagocytosis

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 destroys lymphocytes.

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

Renal function decreases

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

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 appears mildly ill, listless, and disheveled.

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.

The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?

The injection area swells if the client has developed antibodies against the antigen.

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.

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

Immunocompetence is the ability of the immune system to cooperatively protect a person from external invaders and the body's own altered cells. Immunocompetence is maintained by white blood cells and:

lymphoid tissue.

Which of the following is the most severe form of hypersensitivity reaction?

Anaphylaxis

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?

Neutrophils

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

The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which statement correctly describes the process of autoimmunity?

The normal protective immune response attacks the body, damaging tissues.

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 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."

The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?

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

A nurse is monitoring a client who developed facial edema after receiving a medication. Which white blood cells stimulated the edema?

Basophils

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

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?

Naturally acquired active immunity

A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?

A cell-mediated response

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

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses?

Immunosenescence

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

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