CH 35
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?"
A patient tells the nurse, "I can't believe I have ineffective immune function and am getting sick again. I exercise rigorously and compete regularly." What is the best response by the nurse?
"Rigorous exercise can cause negative effects on immune response."
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 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 assessment should be completed if immune dysfunction is suspected in the neurosensory system?
Ataxia
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
Which of the following cell types are involved in humoral immunity?
B lymphocytes
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
A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?
Engulfment and digestion of bacteria and foreign material
Which of the following protective responses begin with the B lymphocytes?
Humoral
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 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
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
Which medication classification is known to inhibit prostaglandin synthesis or release?
Nonsteroidal anti-inflammatory drugs in large doses
Which of the following cells destroy antigens already coated with antibody?
Null lymphocytes
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
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 is caring for a client with a suspected immune system disorder. What test would be ordered if a deficiency or excess of immuneglobulins was suspected?
Protein electrophoresis
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?
T-cell lymphocytes survey proteins in the body and attack the invading antigens.
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?
The client appears mildly ill, listless, and disheveled.
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 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
What types of cells are the primary targets of the healthy immune system? Select all that apply.
cancerous cells foreign cells infectious cells
A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to:
infection because the spleen removes bacteria from the blood.
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
neutrophils and monocytes.
Which of the following is a age-related change associated with the immune system?
Decreased antibody production
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.
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.
A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder?
The immune system recognizes one's own tissues as "foreign."
