Chapter 15 PrepU

The nurse is assessing a new client admitted to a nursing home. The client asks the nurse to explain interleukins. The nurse would include which information?

"Interleukins help the immune system with inflammation." Explanation: Interleukins help the immune system with inflammation. Interleukins do not directly affect acid-base balance, infection, or anemia.

A client who waiting for an organ transplant asks the nurse why the donor organ must be matched. Which response by the nurse would be most appropriate?

"The closer the match, the less risk there is of rejection." Explanation: All transplants, except autotransplantation, produce an immune response. Therefore, matching a donor's HLA markers as closely as possible to those of the recipient for histocompatibility is essential. The more closely the foreign cells can be matched, the less aggressive the immune reaction will be to the donated tissue.

A client is admitted to a skilled health facility after total hip replacement. The client asks if the nurse would explain the types of cells that circulate in the blood. The nurse would include which information?

"There are three distinct cells that circulate in the blood: red blood cells, white blood cells, and platelets." Explanation: There are three distinct cells that circulate in the blood: red blood cells, white blood cells, and platelets. Potassium, sodium, and CO2 are electrolytes, not cells.

A nurse is caring for a client who has undergone organ transplant surgery. The client asks the nurse what antibodies are. What is the best response by the nurse?

A protein substance that the body produces in response to an antigen

The nurse is caring for a client with leukemia and is describing the effects of the disease and its treatment on myelocytes. What cell should the nurse describe?

Basophils

A client is experiencing an inflammatory response following an injury. What assessment finding would confirm the role of thromboxanes in the inflammatory process?

Bleeding has stopped at the injury site Explanation: Platelet aggregation and blood clotting are the result of the action of thromboxanes. Thromboxanes have no effect on pain or vital signs. They cause vasoconstriction, which would be more associated with pallor than redness.

After teaching a group of students about arachidonic acid, the instructor determines that additional teaching is needed when the students identify which substance as being released due to this acid?

Bradykinin Explanation: Bradykinin causes the release of arachidonic acid, not vice versa. Arachidonic acid causes the release of prostaglandins, leukotrienes, and thromboxanes.

Some leukotrienes have the ability to attract neutrophils and to stimulate them. This property is known as:

Chemotaxis. Explanation: Chemotaxis is the property of drawing neutrophils into the area.

Which of the T cells is responsible for destroying pathogens by punching holes in their cell membrane and by secreting cytokines/lymphokines?

Cytotoxic T cells Explanation: Cytotoxic T cells destroy the pathogens, while the helper T cells assist in the process and the memory T cells recall the pathogen for future antigen encounters.

The nurse assists and educates clients on the difference between nonspecific and specific immunity. Which would be the best description by the nurse to the clients about cell-mediated immunity?

Destruction of antigens by T cells Explanation: Humoral immunity refers to destruction of antigens by antibodies. Immunity can be inborn or acquired. Both naturally and artificially acquired immunity can be actively or passively acquired. Cell-mediated immunity refers to destruction of antigens by T cells. Exposure to disease-causing organisms over one's lifetime stimulates the process of acquired immunity. Humoral or antibody-mediated immunity protects the body against circulating disease-producing antigens and bacteria.

Burn victims have a high potential for infection due to the destruction of several defense mechanisms, external and internal. Why would this be the case?

Disruption of intact skin Explanation: The body's primary external defense mechanism is intact skin, which prevents entry of foreign substances and produces secretions that inhibit microbial growth.

A nurse is addressing a group of nursing students about gamma globulins. What is the best response to the nursing students about the function of IgA?

Helpful in defense against invasion of microbes via nose, eyes, lungs, and intestines

A deficiency in what area would result in an inhibition of the inflammatory response?

Histamine

A group of students are reviewing class material about lymphoid tissue. The students demonstrate a need for additional teaching when they identify this as lymphoid tissue?

Histamine Explanation: Histamine is a substance released when a cell membrane is injured and is not considered lymphoid tissue. Bone marrow, the thymus gland, and the spleen are lymphoid tissues.

A client has sought care because of seasonal allergies that are having a negative effect on the client's quality of life. The nurse should recognize the role of what immunoglobulin in this client's health problem?

IgE Explanation: IgE seems to be related to allergic responses and activation of mast cells. IgG contains antibodies made by memory cells that circulate and enter the tissue. IgM is the first immunoglobulin released on first exposure to an antigen. IgA is secreted by plasma cells in the GI and respiratory tracts and in epithelial cells.

In an allergic reaction, the immunoglobulin that binds to mast cells that release histamine is the:

IgE. Explanation: IgE immunoglobulin response in allergic response and parasitic infections, while the IgA is the primary defense against local infections in mucosal tissues. IgG protects against bacteria, toxins and viruses, and activates the complement system. The IgD acts as an antigen receptor for initiating the B cells.

In the earlier stages of an inflammatory process leukocytosis occurs due to a(n):

Increase in circulating neutrophils Explanation: Leukocytosis occurs due to an increase in circulating neutrophils and Eosinophils. Leukocytosis does not occur because of increased cell production, and blood supply is typically increased as part of the inflammatory process.

A client is lying on the back for more than 3 hours. The client develops a reddened area on the coccyx. What response is noted with the development of the reddened area?

Inflammation Explanation: The cellular response to injury involves inflammation, a generalized reaction to any tissue damage, which attempts to remove the damaging agent and repair the damaged tissue. The cellular response related to a decubitus ulcer does not involve a decrease in pH, increased protein catabolism, or the direct inhibition of cell growth.

A client with is admitted to the ICU with gunshot wounds in the chest and thigh. Extensive edema is present. Anticipating a generalized reaction to tissue damage, the nurse concludes that the client's edema is due to:

Inflammatory process. Explanation: The cellular response to injury involves inflammation, a generalized reaction to any tissue damage, which attempts to remove the damaging agent and repair the damaged tissue. The hemodynamic aspect of inflammation includes vasodilation, which increases blood supply to the injured area, and increased capillary permeability, which allows fluid to leak into tissue spaces.

A client comes to the clinic to learn about interferons. What would the nurse include in the lesson plan?

Interferons modulate the response of the immune system to viruses, bacteria, cancer, and other foreign substances. Explanation: Interferons modulate the response of the immune system to viruses, bacteria, cancer, and other foreign substances.

What best describes the role of the major histocompatibility complex as a barrier defense?

It allows the body to distinguish cells as foreign or belonging to the person. Explanation: Major histocompatibility complex allows the body to be able to distinguish between self-cells and foreign cells. The skin physically prevents pathogens from entering the body. The mucous membranes protect exposed areas that are not covered by skin. Gastric acid destroys would-be pathogens that are ingested or swallowed.

Which best explains the role of mucus as a barrier for the body's defense?

It traps the foreign material and thus inactivates it. Explanation: Mucus is sticky and traps invaders and inactivates them for later destruction and removal by the body. It does not promote their removal. Cilia sweep away captured pathogens and also move them to an area, causing irritation and leading to removal by coughing or sneezing.

A patient is exposed to a viral infection. What role will interferon play based on this exposure?

It will interfere with virus replication. Explanation: Interferons interfere with the ability of viruses in infected cells to replicate and spread to uninfected cells. Interferons will not stimulate B lymphocyte activity, stem cell multiplication, or growth of lymphoid cells.

The nurse assists and educates clients about the structure and function of the immune system. Cells in the bone marrow are capable of developing into different types of blood cells. Based on this information, the nurse should tell a group of nursing students that which cells are considered the cornerstone of the immune system and alone have the ability to recognize foreign substances in the body?

Lymphocytes Explanation: Lymphocytes, not erythrocytes, leukocytes, or thrombocytes, are the cornerstone of the immune system; they alone have the ability to recognize foreign substances in the body.

What would be considered the body's last barrier of defense?

Major histocompatibility complex Explanation: The major histocompatibility complex is the body's last barrier of defense, which involves the ability to distinguish between self-cells and foreign cells. The skin is considered the body's first line of defense. The mucous membranes and gastric acid are also two other body defenses.

A client's immune response include phagocytosis of the bacteria that have infected the client. What cells are capable of performing this role in the immune response?

Monocytes

A patient presents to the emergency department of the hospital with a swollen, reddened, painful leg wound and has been diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) cellulitis. The patient's physician has ordered a complete blood count and white cell differential. Which blood components would the physician most likely anticipate to be elevated?

Neutrophils Explanation: Increased neutrophils are associated with inflammation in general and bacterial infections in particular. Platelets play a role in inflammation but their levels would not rise to the same extent as would neutrophils. Eosinophils are not strongly associated with bacterial infection and basophils would not increase to the same degree as neutrophils

Once the inflammatory response is under way, which cells engulf and digest the injured cells or the invader?

Neutrophils Explanation: Once the inflammatory response is under way and neutrophils become active, engulfing and digesting injured cells or the invader, they release a chemical that is a natural pyrogen, or fever-causing substance. Basophils are myelocytic leukocytes that are not capable of phagocytosis. Eosinophils are circulating myelocytic leukocytes whose exact function is not understood. Monoctyes are mature leukocytes that are capable of phagocytizing an antigen.

A client has developed a wound infection and leukocytes are leaving the bloodstream to perform phagocytosis on pathogens. What white cells are most likely performing this function?

Neutrophils Explanation: When an injury or invasion occurs, neutrophils are rapidly produced and move to the site of insult to attack the foreign substance. Basophils are not capable of phagocytosis but contain chemicals that can initiate or maintain an immune response and may be fixed or circulate in the blood. Eosinophils are not well understood but are often found at the site of an allergic reaction. Monocytes are capable of phagocytosis and show up in greater numbers after the neutrophils to remove debris.

Which event in the inflammatory response would the nurse correlate with the action of bradykinin?

Pain Explanation: Bradykinin causes local vasodilation and also stimulates nerve endings to cause pain, not numbness. Vasoconstriction and platelet aggregation result from the action of thromboxanes.

A client's current immune response includes the release of basophils . What aspect of the client's immune response will be performed by these leukocytes?

Releasing histamine Explanation: Basophils contain chemical mediators important for initiating and maintaining an immune or inflammatory response, such as histamine. Neutrophils are responsible for phagocytosis. Basophils are not capable of phagocytosis. Macrophages process antigens. Eosinophils may be involved with allergic reactions, but their exact function is unknown.

The classic signs of inflammation include:

Rubor, swelling, and pain. Explanation: The classic signs of inflammation are rubor (redness), tumor (swelling), calor (heat), and dolor (pain).

Glands in which areas secrete chemicals that destroy or repel many pathogens?

Skin

The nurse assists and educates clients on the difference between nonspecific and specific immunity. The body possesses several defense systems. Which nonspecific defense mechanism provides a physical barrier and secretes enzymes that kill or reduce the virulence of bacteria?

Skin Explanation: The skin provides a physical barrier and secretes enzymes that kill or reduce the virulence of bacteria. Mechanical reactions, such as coughing or sneezing, help remove pathogenic material. Chemical barriers, such as the normal flora (microorganisms) of the GI system, neutralize or kill microorganisms. Tears dilute and wash away irritating substances and microbes.

The first physical line of defense in innate immunity is:

Skin and mucous membranes. Explanation: The first physical line of defense in immunity is the skin and mucous membranes, which prevent pathogens from entering if they are intact. The other options are cellular level protection.

What does the clinical presentation of an inflammatory reaction include? (Select all that apply.)

Swelling Pain Heat Redness Explanation: The clinical presentation of an inflammatory reaction is heat, redness, swelling, and pain.

Which autoacids facilitate platelet aggregation?

Thromboxanes

Which gland is responsible for the final differentiation of the T cells and for regulating the actions of the immune system?

Thymus Explanation: The thymus gland is responsible for the final differentiation of the T cells and for regulating the actions of the immune system.

A nurse assesses a client and notes an area that is reddened and warm. The nurse understands that these findings are related to:

Vasodilation. Explanation: Warmth or heat and redness are due to vasodilation. Activation of the nerve fibers would be noted as pain. Fluid leakage into tissues would be assessed as swelling. Pyrogen release would result in a fever.

Within an infected wound bed, many cell types are involved in protecting the host and eliminating the "foreign invaders" to promote wound healing. How does the identification of body tissues from foreign substances occur?

Via the immune system Explanation: The immune system detects and eliminates foreign substances that may cause tissue injury or disease.

A harried mother of four preschoolers voices confusion during their pediatric appointment that three of her immunized children avoided contracting chicken pox but the fourth "had a hard case." After describing the benefits the vaccine provided her children, the nurse explains that her three children avoided infection due to their:

active immunity.