Chapter 36 PrepU for Med Surge III
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?"
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.
Cytotoxic T cell
Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?
Ataxia
A patient with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. What is the immune response that predominates in this situation?
Cellular
All the following items are related to cancer. Which does not affect the immune system?
Diagnostic tests for cancer
A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used?
Digestive enzymes destroy its protein structure.
The nurse practitioner explains to the patient scheduled for the RAST that the test will measure allergen-specific __________.
Ig E
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
SATA 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
A patient in the intensive care unit has a diagnosis of immune thrombocytopenia (ITP) and has been treated with an infusion of intravenous immunoglobulin (IVIG). The therapeutic effects of IVIG are an example of:
Passive acquired immunity
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
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?
Type 1
A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens?
back
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
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."
SATA Which of the following is accurate regarding acquired immunity? Select all that apply.
> 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 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
While monitoring the patient's eosinophil level, the nurse suspects a definite allergic disorder when seeing an eosinophil value of what percentage of the total leukocyte count?
15% to 40%
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
A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of his last tetanus shot, which he tells the nurse was more than 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what?
An antibody
While taking the health history of a newly admitted client, the nurse asks for a list of the client's current medications. Which of the following medication classifications would place the client at risk for impaired immune function?
Antimetabolites
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
Which of the following cell types are involved in humoral immunity?
B lymphocytes
An individual's exposure to an airborne pathogen has prompted an immune response that includes both cellular and humoral components. Which of the following activities is most closely associated with the humoral immune response?
B lymphocytes produce antibodies that are specific to the pathogen.
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)
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.
Which immunity type becomes active as a result of infection by a specific microorganism?
naturally acquired active immunity
SATA A client has recently been diagnosed with rheumatoid arthritis, and is also receiving further testing for disorders of the immune system. The client works as an aide at a facility caring for children infected with AIDS. Which factors will hold significant implications during the client's assessment? Select all that apply.
work environment history of immunizations and allergies use of other drugs
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 client has a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?
Protein electrophoresis
Nursing students have learned that removal of specific organs may place the patient at risk for impaired immune function. The students are taught that it is important, while taking the patient's health history, to ask the patient if he or she had surgical removal of what organ that may lead to impairment of the immune system?
Spleen
A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?
"If I notice tingling in my lips or mouth, gargling may help the symptoms."
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
While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. What strategies would have a positive effect on the immune system?
Biofeedback, relaxation, and hypnosis
A nurse is caring for a client undergoing evaluation for possible immune system disorders. Which intervention will best help support the client throughout the diagnostic process?
Educate the client about the diagnostic procedures and answer their questions about the possible diagnosis
When the body is in contact with an allergen, this lymphocyte, located in the respiratory and intestinal mucosa, triggers the release of histamine. Choose that lymphocyte.
Ig E
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
At 39 weeks' gestation, a pregnant client visits the physician for a scheduled prenatal checkup. The physician determines that the fetus has developed an infection in utero and sends the client for an emergency cesarean delivery. The client is very concerned about the health of her unborn child. Based on knowledge of the immune system, the delivery room nurse explains about which immunoglobulin that will be increased in the fetus at the time of birth and will be actively fighting the infection?
IgG
Which immunoglobulin assumes a major role in bloodborne and tissue infections?
IgG
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 type of immunity becomes active as a result of infection by a specific microorganism?
Naturally acquired active immunity
A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a storm door. The fall resulted in a 6 cm laceration of the right antecubital. The nurse caring for this patient knows that the site of the injury will have an invasion of what?
Phagocytic cells
A client comes to the clinic and informs the nurse that he feels as though he has allergies. What laboratory test results will be a positive indicator for an allergic disorder?
Radioallergosorbent blood test (RAST) of 3
Which condition is associated with impaired immunity relating to the aging client?
Renal function decreases
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.
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."
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.
A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing?
The skin will be scratched, and applying a small amount of the liquid test antigen to the scratch, usually on the back.
A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this client for which reason?
Use of anti-rejection drugs
A 38-year-old 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. Which is the most important factor related to the client's assessment?
Use of other drugs
A nurse has been administering seasonal influenza vaccinations to the residents of a long-term care facility. One resident has refused the vaccinations, stating that he believes the vaccination to be a cause of influenza infection rather than a protection against it. The nurse's response to this resident should encompass which of the following facts about vaccination?
Vaccination prompts the body to produce antibodies against influenza.
Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that:
filter bacteria from tissue fluid.
SATA What types of cells are the primary targets of the healthy immune system? Select all that apply.
infectious cells foreign cells cancerous cells
A nurse has developed a latex allergy and now uses latex-free purple gloves to avoid a hypersensitivity response. What in this nurse's reaction to latex differs from all other types of hypersensitivity responses?
no antibody production
A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse?
"White blood cells are produced in the bone marrow."
A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?
Assure the client that this is a normal reaction
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 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 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)
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 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
SATA A patient with a recent diagnosis of HIV infection has expressed to the nurse that he is motivated to learn as much about his disease as possible. The patient has heard and read about the role of the different T cells, but is unclear of their roles in the immune response. Which of the following roles of T cells should the nurse identify? Select all that apply.
Stimulating the immune system Secreting cytokines Directly attacking antigens Activating other T cells
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 nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
neutrophils and monocytes.
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?
Lymphocyte
A nurse is teaching a community group about healthy lifestyles. A participant asks about how to maintain a healthy immune system. The nurse informs the group that which factor will positively affect the immune system?
Strong family and community connections
A teenage boy is undergoing allergy testing and has had blood work drawn as part of the diagnostic workup. When reviewing the patient's laboratory results, the nurse should pay particular attention to the levels of what white blood cell (WBC) component?
Eosinophils
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?
The client's use of other drugs
Which allergic reaction is potentially life threatening?
angioedema
During an allergic reaction, histamine is released in about 15 minutes. The patient usually takes an antihistamine that has an affinity for bronchiolar smooth muscle cells (an H2 receptor). Which of the following is most likely the drug described?
Benadryl
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 woman who has experienced severe seasonal allergies in recent years has been referred for allergy skin testing. The nurse at the allergy clinic should be aware of the need to take precautions against the patient's risk of which of the following nursing diagnoses?
Impaired gas exchange
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
The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?
Natural killer cells
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
SATA The nurse is reviewing the client's medications. What antihistamines are contraindicated for a client with narrow-angle glaucoma? Select all that apply.
diphenhydramine loratadine cetirizine brompheniramine
A nurse is taking the health history of a newly admitted client and asks for a list of the client's current medications. Which medication classification would NOT place the client at risk for impaired immune function?
Inotropics
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?
Natural immunity
In its attempt to suppress allergic responses, the body releases several chemicals which have a role in mediating physical reactions. Epinephrine, which interferes with vasoactive chemical release from mast cells, is instrumental in suppressing which type of hypersensitivity response?
type I
A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact her bone marrow is unable to produce a sufficient amount of what?
Lymphocytes
