MEDSURG EAQ's Ch.16 Immunity
A patient with influenza B reports having received the flu shot last year and asked the nurse why he or she became sick. Which answer with the nurse provide?
" The influenza virus changes each year, and your body needs to build new immunity"
Which Statement describes the age related changes in immune function?
-Decreased number of macrophages and neutrophils -increased risk for infections by micro organisms -decreased ability of the immune system to distinguish between self and non-self cells RATIONALE In the older adult the number of neutrophils and macrophages are reduced, as are their functions. As a result, some of the normal responses to infection injury are reduced. This results in increased risk for infection by micro organisms. Aging causes a decreased ability of the immune system to distinguish between self and non-self cells. With the loss of recognition of self, the numbers of circulating auto antibodies increase, increasing the risk for auto immune diseases in older adults. Older adults may have a decreased T cell response and decreased antibody production, resulting in a compromised immune system
Which feature of the immune system does the nurse include when explaining how the immune system works to a patient? Select all that apply
-Immunity protects against harmful cells -immunity protects against harmful microorganisms -cytokines and growth factors are components of immunity RATIONALE Immunity protects us from harmful cells, such as cancer cells and micro organisms. The components of immunity are cellular products, such as cytokines, growth factors, and antibodies. Immune over activity is harmful because it can lead to autoimmune disorders and transplant rejections. Reduced immunity may be either temporary or permanent, depending on the cause, but always endangers the patient's health
Which statement describes the cause of decreased heart function in a patient after a myocardial infarction? Select all that apply
-Inability of the heart muscles to replace the damaged tissue, because of it's not invading nature -Inability of the scar tissue to function like the lost tissue, leading to compromise cardiac function -White blood cells involved in the process trigger new blood vessel growth and scar tissue formation
Which statement about how do you immune system is organized is correct? Select all that apply
-The immune system is influenced by many systems -some immune cells mature in the body after leaving the bone marrow -mature immune system cells circulate through the blood to different body sites RATIONALE The immune system is influenced by the nervous system, the Endocrine system, and G.I. system. Most immune cells mature in the bone marrow, but a few mature in the body after leaving the bone marrow. Mature immune system cells travel to different body sites to carry out specific functions once they are released into the bloodstream. The immune system is not located in any one body part
When discussing cell types involved in cell mediated immunity (CMI), what information about T cells need to be included? Select all that apply
-helper T cells have the T4 proteins on their membranes -most T cells have more than one antigen on their cell membrane -regulator T cells known as Tregs start out as a type of T4 cells and become sensitize for self recognition in the thymus -helper T cells secrete cytokines that can enhance the activity of other white blood cells and increase overall immune function -healthy adults have millions of T lymphocyte clones that are able to recognize millions of environmental antigens
Which nursing intervention is helpful and promoting the health of an older adult who is deficient in antibody mediated immunity? Select all that apply
Administration of the flu shot administration of the shingles vaccine administration of the pneumococcal vaccine RATIONALE Older adults are less able to make new antibodies in response to the presence of new antigen; therefore measures to prevent infection are needed. The patient should receive an annual flu shot, shingles vaccine, and pneumococcal vaccine. Acyclovir and azithromycin are helpful only and treating acute episodes of viral and bacterial infections, and are not used for prevention
Which information about agglutination needs to be included when discussing key terms related to immunology?
Agglutination is a result of antigens and antibodies clumping together RATIONALE Agglutination is the term for the clumping affect that occurs when antibodies link antigens together. Some laboratory tests rely on this process to detect disease. Both antigens and antibodies must be present for this action to take place.
The nurse identifies that which test will help determine the effectiveness of the vaccination that a patient received?
Antibody level RATIONALE Antibody levels in the blood rise in response to vaccination to the specific antigen in the vaccine. An absolute neutrophil count determines the actual number of circulating mature neutrophils. A WBC count determines the total number of circulating WBCs. A WBC differential count shows the number and percentage of the different types of circulating WBCs
The nurse is preparing to administer a tetanus booster to a patient after the patient experiences in injury. Which type of immunity is the nurse is providing this patient?
Artificial active RATIONALE When the nurse administers the vaccine, it provides artificial active immunity to the tetanus toxin. Natural active immunity occurs when a person is exposed to an antigen because of an infection; this would occur when the patient is exposed to hepatitis C. Natural passive immunity takes place between a mother and the fetus or infant. Artificial passive immunity is through antidote after being bitten by a poisonous snake or a rabid dog
The nurse identifies that which type of immunity would be helpful in preventing tetanus in a high-risk patient?
Artificial active RATIONALE Artificial active immunity (vaccinations and immunizations) is required to prevent tetanus because it affects are long lasting
The nurse recognizes that which type of immunity occurs when an older adult receives a booster of tetanus?
Artificial active immunity RATIONALE A vaccination or immunization is an artificial active immunity. This type of immunity is used to prevent infections or illnesses such as tetanus, diphtheria, or polio. Active immunity occurs when antigens enter the body and the body responds by making specific antibodies against the antigen. Adaptive immunity is an adaptive response to invasion by organisms or foreign proteins. Natural active immunity occurs when an antigen enters the body without human assistance. The body responds by actively making antibodies against the antigen, as in chickenpox infection
Which type of immunity does the patient obtain when receiving an anti-venom after sustaining a snake bite?
Artificial passive immunity RATIONALE Artificial passive immunity occurs when antibodies already formed in an individual or animal are being transferred to a non-immunized individual. Artificial passive immunity is used in emergency conditions when the patient does not produce antibodies required for the specific antigen. Natural Active immunity is developed by the host in response to the antigen that enters by natural infections, such as influenza A virus. Artificial active immunity is developed through immunization or vaccination. Natural passive immunity occurs when antibodies are passed from mother to child through the placenta and also in the infancy stage through colostrum and breastmilk
Which nursing activities is the nurse delegate to assistive personnel?
Assist with bathing for a patient with chronic rejection of a liver transplant RATIONALE Assisting with bathing for a patient with chronic rejection of a liver transplant can be delegated to AP. Changing the dressing for a patient with a low absolute neutrophil count requires a licensed nurse and should not be delegated because of the high risk for infection. Teaching about medications and assessments are within the scope of practice of the registered nurse
When caring for a patient with sepsis the nurse expect that which component of the differential white blood cell count will be elevated?
Band neutrophils RATIONALE An increase in the number of band neutrophyils is expected in the patient with sepsis. The patient bone marrow cannot produce enough mature neutrophils to keep pace with the continuing infection. This leads to a left shift or bandemia, which is an increase in the less mature band cells. A left shift is a decrease in the number of segmented neutrophils or polymorphonuclear cells, which are mature neutrophils
The nurse is developing a plan of care to prevent infection for an older adult admitted for an exacerbation of COPD. Which finding would leave the nurse to suspected infection is beginning?
Changes in level of consciousness RATIONALE An older adult does not present with the same immune response as a younger person. The most common manifestation of infection in older adults is a change their level of consciousness. Older adults have decreased antibodies and WBC production. The older adult does not develop a fever with the onset of an infection because of a decreased immune response. By the time a fever begins, an older adult may be septic
Which age related change an immunity is the reason that the nurse encourages an older adult to receive a flu shot?
Decline in natural antibodies RATIONALE All the patients are in able to generate new antibodies in response to the presence of new antigens. Hence, they should be encouraged to receive immunization such as a flu shot, shingles vaccine nation, and pneumococcal vaccination. Thymic activity decreases with aging in the number of circulating T lymphocytes decreases. This increases the risk for bacterial and fungal infections in the older patient.
What is the function of the cytokine tumor necrosis factor (TNF)?
Facilitates acute inflammatory response to infectious bacteria RATIONALE Tumor necrosis factors the major cytokeen involved in the cute inflammator response to infectious bacteria. It is responsible for rheumatoid arthritis damage and systemic complications of severe infection or sepsis and the induction of cell death. The granulo-sy colony stimulating factor increases the number and maturity of neutrophils. Thrombopoetin increases the growth and differentiation of platelets. Interleukin-1 stimulates the production of prostaglandins and increases the growth of CD4+ T cells
Which growth factor increases the number and maturity of neutrophils?
Granulocyte colony stimulating factor (G-CSF) RATIONALE The G-CSF increases the number and maturity of neutrophils. Erythropoietin increases the growth and differentiation of erythrocytes. Thrombopoietin increases The growth and differentiation of platelets. The GM-CSF increases the growth and maturation of myeloid stem cells
The nurse is caring for a patient with neutropenia, a white blood cell count of .8 cells/mm3, and an absolute neutrophil count of 1100. Which cytokine would the nurse expect to administer to increase these values?
Granulocyte colony stimulating factor (G-CSF) RATIONALE The patient has a Low neutral fill count. To increase the number of neutral fills the nurse should administer the cytokine G-CSF. Erythropoietin would be administered to increase red blood cells. Thrombopoietin would increase the platelet count. GM-CSF would be administered if trying to increase myeloid stem cells
Which immunoglobin Julen antibodies deficiency does the nurse expect any patient with low humoral immunity, who experiences recurrent episodes of intestinal and urinary infections?
IgA
Which kind of immunoglobulin anti-body helps in the prevention of respiratory tract infections?
IgA RATIONALE IGA is an anti-body that is present in high concentrations in the secretions of mucous membranes of the intestinal mucosa. These help in preventing infections in the respiratory tract, G.I. tract, and Genitourinary tract. IgE is present in variable concentrations in the blood and is associated with antibody mediated hypersensitivity reactions. IgG compromises 75% of the immunoglobulins present in human serum. It is produced particularly during secondary immune responses to provide sustained, long-term immunity against invading microorganisms. IgM is the first antibody to appear in primary immune responses and indicates that an infection has been acquired recently
Which immunoglobulin antibodies bind to basophils and is involved and causing antigen antibody mediated hypersensitivity reactions?
IgE RATIONALE The IgE antibodies bind to basophils and is involved in causing antigen antibody mediated hypersensitivity reactions. IgA is helpful in preventing genitourinary and respiratory infections. IgG provides long-term immunity against invading microorganisms. IgD Is co-expressed with IgM and ask is a receptor on unsensitized B lymphocytes
Which positive laboratory result will the nurse correlate with a current active infection of herpes zoster (shingles) ?
Immunoglobin M (IgM) RATIONALE A positive IgM will be present because of the development of newly sensitized be cells. IgA provides mucosal immunity. IgD is a B cell antigen receptor. IgG is positive after infection has subsided
Which antibody level would the miss expect to be elevated in a patient after an anaphylactic reaction?
Immunoglobulin E (IgE) RATIONALE IgE is produced from an anaphylactic reaction. IgA prevents infections in the respiratory and genitourinary tract. IgG are antibodies formed from last exposures. IgM is formed from new exposure
Which statement does the nurse include when discussing the action of the interleukin-1 (IL-1) cytokine?
It induces fever RATIONALE IL-1 is a proinflammatory cytokine that induces fever. Tumor necrosis factor is a pro inflammatory cytokines that induces cell death and participates in graft rejection. Interleukin-6 is a pro inflammatory cytokines that stimulates the liver to produce fibrinogen
The nurse is preparing to administer an antibiotic to a patient with an infection. Which effect will occur as a result of this medication?
Lysis RATIONALE Antibiotics kill bacteria through lysis, which is destruction of the cell membrane. An activation occurs with antigens by rendering them harmless. With precipitation, anti-body molecules bind so much antigen that large antigen antibiotity complexes are formed. These complexes cannot stain suspension in the blood instead, they form a large precipitate, which then can be acted on and removed by neutrophis and macrophages. Precipitation is similar to but is a larger response than agglutination, which is when antibodies pair with antigens and form complexes
A patient presents to the urgent care center after being exposed to hepatitis A. Which type of immunity with the nurse expect the patient to have?
Natural active RATIONALE Natural active immunity occurs when he person is exposed to an antigen without vaccination; this would happen when the patient is exposed to hepatitis A.
Which cell in the human body contributes to the cell mediated immune system?
Natural killer cell Helper T cell RATIONALE Natural killer cells participate in cell mediated immunity and attack non-self cells, especially abnormal self cells that have undergone a mutation. Helper T cells enhance immunity by recognizing cells a self and non-self cells and secreting cytokines. Plasma cells, memory cells, and B lymphocytes participate antibody mediated immunity
Which is a physiologic role of natural killer cells? Select all that apply
Nonselectively attack nonself cells attack mutated and malignant cells attack graphs and transplanted organs RATIONALE The physiologic role of natural killer cells are to nonselectively attack non self cells, mutated cells, malignant cells, graphs, and transplanted organs. They are not involved in triggering allergic disorders or autoimmune disorders.
Which function of regulator T cells (Tregs) need to be included when providing education about cell mediated immunity?
Prevent hypersensitivity on exposure to nonself cells or proteins RATIONALE Cell mediated immunity is provided by different types of T cells and natural killer cells. Tregs prevent hypersensitivity and immunity overreactions on exposure to nonself cells or proteins. This action prevents the formation of antibodies directed against normal, healthy selves, which is the basis for many auto immune diseases. Helper T cells recognize self cells versus nonself cells and secrete lymphokines. Cytotoxic T cells destroy cells that contain a processed antigens human leukocyte antigen. Natural killer cells destroy unhealthy or abnormal self cells, cancer cells, and virally infected body cells
A patient who experienced an anaphylactic reaction asks the nurse what prevents the body from attacking itself. Which cells prevent this from occurring?
Regulator T-cells RATIONALE the regulator T-cells are sensitized to recognize the body's own cells as familiar and prevent immunity overreactions. Cytokines are produced by helper T-cells to call other white blood cells to the area to attack foreign cells, Gamma globulins are antibodies formed from previous exposure to foreign cells
When a patient who is exposed to invaders recovers rapidly without damage to healthy body cells, the nurse identifies that which immune response protected the patient?
Self tolerance RATIONALE The ability to recognize self versus non-self is necessary to prevent healthy body cells from being destroyed along with the invaders. This meets the patient protection needs. The body has some defenses to prevent organisms from gaining access to the internal environment, such as intact skin and mucous membranes; however they are not perfect. Invasion of the body's internal environment by organisms often occurs. Inflammation provides immediate protection against the effects of tissue injury and invading foreign proteins. The inflammatory response is immediate but short term against injury or invading organisms; it does not provide true immunity. Seven steps phagocytosis are needed to produce a specific antibodies directed against a specific antigen whenever the person is exposed to that antigen
Which information does the nurse include in a patient education about immunity when the patient receives a vaccine for the prevention of rabies?
The antibodies are produced in another person or animal RATIONALE The antibodies were produced in another person or animal; the patient is receiving artificial passive immunity. Artificial active immunity involves placing a small amount of specific antigen as a vaccination into a person; this type of immunity lasts for many years. However, a smaller dose may have to be repeated. Natural active immunity occurs when the antigen that triggers antibodies production also causes the disease. In this case, the person does not become ill after a second exposure to the same antigen
The nurse is obtaining bloodwork for my patient waiting for a kidney transplant because of renal failure. The patient asked why so many tubes of blood are being obtained. Which response with the nurse make that relates to rejection?
Your cells have antigens that must match the donor cells or the body will attack the new kidney RATIONALE It is essential that the new organ matches the same human leukocyte antigens (HLA) as this is what the immune system identifies as "self" to prevent rejection