Chp. 35: Assessment of immune Function

A nursing instructor is giving a lecture on the immune system. The instructors discussion on phagocytosis will include: neutrophils and monocytes. plasma cells and memory cells. regulator T cells and helper T cells. lymphokines and suppressor T cells.

Neutrophils and monocytes These two cells are phagocytes that perform phagocytosis

In which process is the antigen - antibody molecule coated with a stick substance that facilitates phagocytosis?

Opsonization

A nurse is exposed to hepatitis C and receives a shot of gamma globulin. What type of immunity does this nurse have? Artificially acquired immunity Passive Immunity Naturally Acquired immunity Natural Immunity

Passive Immunity Passive immunity develops when ready made antibodies are given to a susceptible person

A laboring mother asks the nurse if the baby will have immunity to some illness when born. What type of immunity does the nurse understand that the newborn will have? Naturally acquired active immunity Artificially acquired active immunity Passive immunity transferred by the mother There is no immunity passed down from mother to child.

Passive immunity transferred by the mother. Mothers pass their antibodies to their children.

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. T-cell and B-cell lymphocytes respond to the body's invasion by macrophages. T-cell and B-cell lymphocytes react to the body's lack of B12 . T-cell and B-cell lymphocytes distinguish harmful treatments from curative treatments

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

The spleen acts as a filter for old red blood cells, holding a reserve of blood in case of hemorrhagic shock. It is also an area where lymphocytes can concentrate. It can be come enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would need to palpate the area of:

Upper left quadrant of the abdomen The spleen is located left of the stomach.

A nurse is teaching a client about the side effects of ibuprofen. The client's learning is determined to be effective based on which statement by the patient describing the drugs effect on the immune system?

"Ibuprofen can cause neutropenia, which can increase my risk of infection" Ibuprofen causes leukopenia and neutropenia

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 dysfunctions, and clinical trials using stem cells are underway in clients with a variety of disorders with an auto immune component"

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. -The nurse should send the client to have the blood drawn without informing him about the specific screening test. -The nurse will call the client with the results of the test. -The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC).

-The nurse ensures a written consent is obtained prior to testing.

The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?

A 65 year old client who had chicken pox when he was 12 years old Half of individuals living to age 65 have had or will develop shingles

A client comes into the ED 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 the heel to shin test - Assess joint mobility using passive range of motion -Review the urinalysis report for hematuria -Assess for hepatosplenomegaly by measuring abdominal girth

Assess for ataxia using the finger to nose test and the heel to shin test this is the ONLY neuro assessment listed

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? Humor, rigorous physical stress, and biofeedback Biofeedback, relaxation, and hypnosis Relaxation, intense competitive exercise, and humor Hypnosis, humor, and chronic illness

Biofeedback, relaxation, and hypnosis

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 Only corticosteroids suppress inflammatory and immune responses.

During the immune response, cytotoxic cells bind to invading cells, destroy the targeted invader and release lymphokines to remove the debris. Which type of T-cell lymphocyte is cytotoxic? Suppressor T Cells Effector T cells regulator T cells helper t cells

Effector T cells Effector T cells are Cytotoxic

A 38-year-old client has been diagnosed with rheumatoid arthritis, an autoimmune disease. During the health history assessment. the nurse learns that the client works as an aide at a facility that cares for children infected with AIDS, does moderate cardiovascular exercises every other day, takes no medication, has no allergies, and eats mainly a vegetarian diet with fish and chicken one to two times each week. Which factor is the most important consideration in determining the status of the client's immune system? Age Diet Gender Environment

G

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 Failure of the immune system to differentiate "self" from "non-self" Decreased phagocytosis by Kupffer cells Decreased sensation and slowing of reflexes

Impaired ciliary action from exposure to environmental toxins

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 Artificially acquired active immunity Passive immunity Natural passive immunity.

Naturally acquired active immunity The client had a recent in

A client has a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?

Protein electrophoresis When there is a suspected immune system disorder, electrophoresis screens for diseases associated with a deficiency or excess of immunoglobulins

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? Removal of the appendix History of radiation therapy removal of the spleen Organ transplantation

Removal of the appendix The appendix doesnt have a direct effect on the immune system

The nurse us 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 Burns depletes the body of essential proteins including immunoglobulins

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? Rigorous, competitive exercise Strong family and community connections Residential exposure to radiation Poor nutritional status

Strong family and community connections

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 membrane of the throat

Immunocompetence is the ability of the immune system to cooperatively protect a person from external invaders and the body's own altered cells. Immunocompetence is maintained by white blood cells and: lymphoid tissue. antibodies. the compliment system. cytokines.

lymphoid tissue.

A patient is being treated in the intensive care unit for sepsis related to ventilator-associated pneumonia. The patient is on large doses of three different antibiotics. What severe outcome should the nurse monitor for in the lab studies? Leukocytosis Bone marrow suppression Oral thrush Rash

Bone marrow suppression