Assessment of the Immune System
Neutrophils Neutrophils (polymorphonuclear leukocytes [PMNs]) are the first cells to arrive at the site where inflammation occurs. Eosinophils and basophils, other types of granulocytes, increase in number during allergic reactions and stress response
A 20-year-old male patient cut his hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which of the following cell types to be elevated first in order to prevent an infection in the patient's hand?
The client's immune system cannot mount a response to the skin test The inflammatory response is a major function of the immune system that is elicited in response to invading foreign material. A person with AIDS has a poorly functioning or non-functioning immune system that will not respond to the injected skin test. Any TB organisms should cause a reaction to the skin test in people with intact immune systems. The nurse cannot accurately speculate on how the skin test was performed or that the solution was outdated.
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?
Radiation destroys lymphocytes. Radiation destroys lymphocytes and decreases the ability to mount an effective immune response. Radiation is not associated with an excess of lymphocytes or an excess or deficiency of hemoglobin
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 of the following reasons?
Educating the patient about the diagnostic procedures and answer questions they may have about the possible diagnosis It is the nurse's role to counsel, educate, and support patients throughout the diagnostic process. Many patients may be extremely anxious about the results of diagnostic tests and the possible implications of those results for their employment, insurance, and personal relationships. This is an ideal time for the nurse to provide counseling and education.
A nurse is caring for a patient undergoing evaluation for possible immune system disorders. Which of the following interventions will best help support the patient throughout the diagnostic process?
Surgical removal of the appendix Removal of the appendix would have no direct effect on the immune system. Organ transplantaion requires immunosupressive drugs, which cause impaired immune function. Radiation therapy destroys lymphocytes. The spleen is an important part of the immune system, and removal of it increases the client's risk for poor immune function
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?
Through the mucous membranes of the throat In a streptococcal throat infection, the streptococcal organism gains access to the mucous membranes of the throat.
A patient arrives at the clinic and informs the nurse that she has a very sore throat as well as a fever. A rapid strep test returns a positive result and the patient is given a prescription for an antibiotic. How did the streptococcal organism gain access to the patient to cause this infection?
They are lymphoid tissues that filter bacteria from tissue fluid. The tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral and nasal passages, they can become infected and locally inflamed. The tonsils and adenoids filter bacteria from tissue fluid.
Decades ago, a typical childhood surgery, after repeated bouts with tonsillitis, was to have a tonsillectomy and adenoidectomy. That was before the role of the tonsils and adenoids were better understood. As it is understood today, what are the roles of the tonsils and adenoids?
Matt will be susceptible to infection because the spleen removes bacteria from the blood. One function of the spleen is to remove bacteria from circulation; therefore, Matt will be more susceptible to infection.
Matt Carson, a 20-year-old college student, was riding his motorcycle home from class when he lost control of the bike and sustained serious internal injuries, including a ruptured spleen. Matt has been taken to the OR to remove his spleen and the ED nurse is meeting with Matt's parents to answer some of their additional questions. Which of the following will be included in the nurse's discussion regarding special considerations following the removal of Matt's spleen?
T-cell lymphocytes survey proteins in the body and attack the invading antigens During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their toxins through agglutination or by causing them to precipitate
The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?
The client appears mildly ill, listless, and disheveled. The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then performs a more comprehensive examination. (
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
Spleen Lymphoid tissues, such as the thymus gland, tonsils and adenoids, spleen, and lymph nodes, play a role in the immune response and prevention of infection. The pancreas, intestines, and liver are not lymphoid tissue
What organ is considered lymphoid tissue?
Humoral A second protective response, the humoral immune response, begins with the B lymphocytes, which can transform themselves into plasma cells that manufacture antibodies. The first line of defense, the phagocytic immune response, involves the white blood cells (WBCs; granulocytes and macrophages), which have the ability to ingest foreign particles. The third mechanism of defense, the cellular immune response, also involves T lymphocytes, which can turn into special cytotoxic (or killer) T cells that can attack the pathogens. Recognition of antigens as foreign, or nonself, by the immune system is the initiating even in any immune response
Which of the following protective responses begin with the B lymphocytes?
Naturally acquired active immunity Immunity to measles that develops after the initial infection is an example of naturally acquired active immunity. Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated toxin), whereas passive immunity develops when ready-made antibodies are given to a susceptible client.
child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection?
Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy but still maintains responsibility for the medications administere
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has 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?
Artificially acquired active immunity Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid. Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection . Not all invading microorganisms produce a response that gives lifelong immunity. There is not a type of immunity called forced immunity. (less)
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?
B lymphocytes B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.
Which of the following cell types are involved in humoral immunity?
Decreased antibody production Age-related changes associated with the immune response include decreased antibody production, suppressed phagocytic immune response, and a failure of immune system to differentiate "self" from "nonself."
Which of the following is a age-related change associated with the immune system?
Decreased renal function Decreased renal circulation, filtration, absorption, and excretion contribute to the risk for UTIs. The antibody production decreases, skin become thinner, and the incidence of autoimmune disease increases with ag
Which of the following is associated with impaired immunity relating to the aging patient?
Anaphylaxis The most severe form of hypersensitivity reaction or immune-mediated reaction is anaphylaxis. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Type III, or immune complex, hypersensitivity involves immune complexes that are formed when antigens bind to antibodies. Type IV, or delayed-type hypersensitivity, occurs 24 to 72 hours after exposure to an allergen
Which of the following is the most severe form of hypersensitivity reaction?
Assure the patient that this is a normal reaction The nurse should assure the patient that this is a normal reaction. When disease-specific antigens are injected, the injection area swells as a result of the patient developing antibodies against the antigen that is introduced. The nurse should also keep in mind that the patient is not necessarily actively infectious if the test results are positive. Rubbing the area gently or even applying ice packs may only aggravate the swelling. The swollen area should be left open to heal by itself. The nurse should await the physician's instructions before advising the patient to use any prescribed analgesics. (less)
A patient undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The patient becomes anxious because the area begins to swell. Which of the following may be used to decrease anxiety in this patient?