Chapter 35: Immune System

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."

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

What type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis?

Cytotoxic T Cell

What stage of protective responses is the phagocytic immune response?

First Stage

The nurse is performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph nodes on the left. What should the nurse document? (Select all that apply.)

Location, size, consistency, reports of tenderness

The third mechanism of defense, the cellular immune response, involves

T lymphocytes, which can turn into special cytotoxic (or killer) T cells that can attack the pathogens

Which stage of the protective responses is the cellular immune response?

The third mechanism of defense

What type of immunoglobulin does the nurse recognize that promotes the release of vasoa ctive chemicals such as histamine when a client is having an allergic reaction?

igE

A nurse is working in a pediatric clinic. After giving a hepatitis B immunization to an infant, the parent asks what kind of protection this provides for the child. What is the nurse's best response?

Active acquired immunity, which lasts many years or a lifetime

Hashimoto's Thyroiditis

An autoimmune disease that damages the thyroid gland, the most common cause of hyperthyroidism

The nurse is obtaining information from a client with Crohn's disease about his medication history. 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 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

A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells?

Epoetin alfa (Epogen)

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.

What two white blood cells have the ability to ingest foreign particles in the first protective response?

Granulocytes and macrophages

Which of the following protective responses begin with the B lymphocytes which can transform themselves into plasma cells that manufacture antibodies?

Humoral

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

IgG

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 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?

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 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 organ is considered lymphoid tissue?

Spleen

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

A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse?

The tissues filter bacteria from tissue fluid

A client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. What is the most important factor related to the client's assessment?

Their use of other drugs

The stem cell is known as

a precursor cell that continually replenishes the body's entire supply of both red and white cells.

Second Protective Response

Begin with the B lymphocytes which can transform themselves into plasma cells that manufacture antibodies

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? A. Surgical history of a partial gastrectomy B. Negative history for radiation therapy C. Previous organ transplantation D. Surgical removal of the appendix

Previous organ transplantation

A client has breast cancer. The nurse is concerned about a compromised immune system in this client for which reason?

Antineoplastic Drug Therapy

Autoimmune Disorder

Any of a large group of diseases characterized by a condition in which the immune system produces antibodies against its own tissues

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 medication classification is known to inhibit prostaglandin synthesis or release?

Nonsteroidal Anti-inflammatory Agents (NSAIDs)

What stage of protective responses is the humoral response?

Second stage

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.

The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents?

Macrophages

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

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

Naturally acquired active immunity

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 (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 responses.

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 immunoglobins

An elderly client is diagnosed with a respiratory infection. While reviewing age-related changes in the immune system, what would the nurse identify as having contributed to this client's infection?

Impaired ciliary action from exposure to environmental toxins

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

T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?

T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.