Infection and Immunity
The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient? a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain
ANS: C Medications for RA are intended to control the inflammation that results from the body's hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.
An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a. Primary immunodeficiency b. Secondary immunodeficiency c. Cancer d. Autoimmunity
ANS: A Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.
The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12-24 hours post operation dependent on which condition? a. His immune system is functioning properly. b. He is properly vaccinated. c. He has an infection. d. The suppressor T-cells in his body are activated.
ANS: A Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body's response to intentional tissue impairment. The redness and swelling at the incision site in the first 12-24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.
Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) a. Uninsured or underinsured status b. Easy access to health screenings c. High cost of medications d. Inadequate nutrition e. Mostly female gender
ANS: A, C, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. Gender has not been shown to be an increased risk factor for infection in the lower socioeconomic population.
The family of a neutropenic client reports that the client "is not acting right." What action by the nurse is the priority? a. Ask the client about pain. b. Assess the client for infection. c. Take a set of vital signs. d. Review today's laboratory results.
ANS: B Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse would definitely assess for infection. The nurse would assess for pain but this is not the priority.
Which set of assessment data is consistent for a patient with severe infection that could lead to system failure? a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours
ANS: B The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.
The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population
ANS: B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.
The nurse is caring for a patient with a diagnosed case of Clostridium difficile. The nurse expects to implement which of the following interventions? (Select all that apply.) a. Administration of protease inhibitors b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission d. Preventing visitors from entering the room e. Administration of intravenous fluids f. Strict monitoring of intake and output
ANS: B, C, E, F Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protective equipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.
The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC)
ANS: B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won't get the disease, but it decreases the potential to contract the illness. No medication is risk free.
The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element? a. Host b. Mode of transmission c. Portal of entry d. Reservoir
ANS: C Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.
While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? a. "My body will treat the new kidney like my original kidney." b. "I will have to make sure that I avoid being around people." c. "The medications that I take will help prevent my body from attacking my new kidney." d. "My body will only have a problem with my new kidney if the donor is not directly related to me."
ANS: C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don't have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.
While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection? a. Bacterial b. Fungal c. Parasitic d. Viral
ANS: C Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.
A nurse is teaching a group of business people about disease transmission. The nurse knows that additional teaching is needed when one of the participants states which of the following? a. "When traveling outside of the country, I need to be sure that I receive appropriate vaccinations." b. "Food and water supplies in foreign countries can contain microorganisms to which my body is not accustomed and has no resistance." c. "If I don't feel sick, then I don't have to worry about transmitted diseases." d. "I need to be sure to have good hygiene practices when traveling in crowded planes and trains."
ANS: C People can transmit pathogens even if they don't currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.
In order to provide an intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? a. Whether a patient has an infection. b. Where an infection is located. c. The type of cells that are being utilized by the body to attack an infection. d. The specific type of pathogen that is causing an infection.
ANS: D People can transmit pathogens even if they don't currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.
The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a. Suppressed immune response b. Hyperimmune response c. Allergic reaction d. Anaphylactic reaction
ANS: D The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.
