3740 IMMUNOLOGIC FUNCTION (31 - 34)

A client taking antiretroviral therapy (ART) for stage 1 of HIV wants new medications because the CD4+ level is not much higher one year after initiation of therapy. The nurse knows that which response will be correct when educating the client about their disease?

"The viral load results can show improvement." Explanation: Laboratory tests evaluate whether ART is effective for a specific patient. An adequate CD4+ response for most clients on ART is an increase in CD4+ count in the range of 50 to 150 mm3 per year, generally with an accelerated response in the first 3 months. Viral load should be measured at baseline and on a regular basis thereafter because viral load is the most important indicator of response to ART. A slowing of the CD4+ level does not indicate that the client is entering another stage of the illness. It also does not mean that the client is missing doses of the medication. There is no reason to question the medications being used to treat the client.

The nurse is caring for a client whose most recent laboratory values reveal a neutrophil level of 21,000 mm3. When preparing to assess the client, the nurse should prioritize what assessment?

Assessing the client for signs and symptoms of infection Explanation: Normal neutrophil levels range from 3,000 to 7,000 mm3. Levels rise in response to infection, so the nurse should monitor the client closely for signs and symptoms of infection. Increased neutrophil levels do not normally affect coagulation or energy levels.

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?

Enzyme-linked immunosorbent assay (ELISA) Explanation: The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. If the ELISA is positive twice then the Western Blot test is run. A CBC and a Schick test are not screening tests for HIV.

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) Explanation: Colony-stimulating factors are cytokines that prompt the bone marrow to produce, mature, and promote the functions of blood cells. CSFs enable stem cells in bone marrow to differentiate into specific types of cells such as leukocytes, erythrocytes, and platelets. Pharmacologic preparation of CSFs, such as epoetin alfa (Epogen), is used to promote the natural production of blood cells in people whose own hematopoietic functions have become compromised. The other medications in A, B, and D are tumor necrosis factor inhibitors.

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which symptoms? Select all that apply. Flank pain Shaking chills Tightness in the chest Hunger Fatigue

Flank pain Shaking chills Tightness in the chest Explanation: Adverse reactions can include reports of flank and back pain, shaking chills, dyspnea, and tightness in the chest, as well as headache, fever, and local reaction at the infusion site.

Which of the following protective responses begin with the B lymphocytes?

Humoral Explanation: A second protective response, the humoral immune response, begins with the B lymphocytes, which can transform themselves into plasma cells that manufacture antibodies. The first line of defense, the phagocytic immune response, involves the white blood cells (WBCs; granulocytes and macrophages), which have the ability to ingest foreign particles. The third mechanism of defense, the cellular immune response, also involves T lymphocytes, which can turn into special cytotoxic (or killer) T cells that can attack the pathogens. Recognition of antigens as foreign, or nonself, by the immune system is the initiating even in any immune response.

The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema?

IgE-mediated hypersensitivity Explanation: A type I, IgE-mediated hypersensitivity can cause severe reaction symptoms such as laryngeal edema and bronchospasm. Irritant and allergic contact dermatitis result in more localized skin reactions. IgG antibodies are important in fighting viral and bacterial infections.

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?

Immunosuppressive agents Explanation: For a client undergoing a hematopoietic stem cell transplant, immunosuppression is started to ensure engraftment of depleted bone marrow. Antibiotic therapy may or may not be indicated. Chest physiotherapy would be appropriate for clients with ataxia-telangiectasis who have chronic lung disease. Anticoagulation would not be used.

After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action?

Jabs the autoinjector into the outer thigh at a 90-degree angle Explanation: To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injecting end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.

Which of the following is the most common HIV-related malignancy?

Kaposi's sarcoma Explanation: Kaposi's sarcoma is the most common HIV-related malignancy and involves the endothelial layer of blood and lymphatic vessels. Kaposi's sarcoma, certain types of B-cell lymphomas, and invasive cervical carcinoma are included in the CDC classification of AIDS-related malignancies.

During a routine checkup, a nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

Kaposi's sarcoma Explanation: Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS.

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 Explanation: The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?

Past substance abuse Explanation: Factors associated with nonadherence include active substance abuse, depression, and lack of social support, as well as neurocognitive impairment, low health literacy, stressful life events, high levels of alcohol consumption, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment.

What is the function of the thymus gland?

Programs T lymphocytes to become regulator or effector T cells. Explanation: The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum. The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle. Options A, B, and C are incorrect.

A client is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurse's priority for care?

Protect the client's airway. Explanation: Anaphylaxis severely threatens a client's airway; the nurse's priority is preserving airway patency and breathing pattern. This is a higher priority than other valid aspects of care, including medication administration, psychosocial support, and assessment of LOC.

A nurse is assessing a client who is experiencing an allergic reaction. What will the nurse identify as resulting from the release of histamine?

Pruritus Explanation: Histamine causes erythema, localized edema in the form of wheals, pruritus, contraction of bronchial smooth muscle resulting in wheezing and bronchospasm, dilation of small venules and constriction of larger vessels, and increased secretion of gastric and mucosal cells, resulting in diarrhea. Vasodilation and hypotension result from bradykinin release.

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective?

Reduced sneezing Explanation: Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, the client shouldn't experience increased salivation or tearing. Because decongestants alleviate congestion, they also relieve headaches, which may be caused by congestion.

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid:

alcohol. Explanation: The nurse should advise a client taking antihistamines not to take it with alcohol or other central nervous system depressants because additive sedative effects can occur.

Which allergic reaction is potentially life threatening?

angioedema Explanation: Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, and aminophylline in severe reactions.

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 Explanation: The scratch or prick test involves scratching the skin and applying a small amount of the liquid test antigen to the scratch. The tester applies one allergen per scratch over the client's forearm, upper arm, or back. The back is more sensitive than the arms.

The nurse is working in an allergy clinic with a client with tuberculosis. What other reaction is a type IV hypersensitivity disorder?

contact dermatitis Explanation: Tuberculosis and contact dermatitis are type IV hypersensitivity reactions. Anaphylaxis, allergic rhinitis, and atopic dermatitis are type I hypersensitivity reactions.

The nurse is administering intravenous vancomycin. What will the nurse initially assess the client for if an allergic reaction occurs?

dyspnea, bronchospasm, and/or laryngeal edema Explanation: Initial nursing assessment and intervention needs to be directed toward evaluating breathing and maintaining an open airway, so the initial assessment will be for dyspnea, bronchospasm, and laryngeal edema. Hypotension, pruritis, and flushing may occur, but the airway is most important.

The nurse is reviewing various medications with a client that can be used to treat allergic disorders. What medication will the nurse identify as an intranasal corticosteroid?

fluticasone Explanation: Fluticasone is an example of an intranasal corticosteroid. Cromolyn sodium is a mast cell stabilizer. Zileuton is a leukotriene-receptor inhibitor. Fexofenadine is a second-generation antihistamine.

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. Explanation: One function of the spleen is to remove bacteria from circulation; therefore, the client will be more susceptible to infection.

The nurse is working with a client with allergies. What will the nurse use to confirm allergies and decrease the risk of anaphylaxis?

intradermal testing Explanation: The diagnosis of anaphylaxis risk is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended. A nasal smear, punch biopsy, and peripheral blood smear would not be used for allergy testing.

When evaluating a client's knowledge about use of antihistamines, what statement indicates further education is required?

"If I am pregnant, I should take half the dose." Explanation: Antihistamines are contraindicated during the third trimester of pregnancy, in nursing mothers and newborns, in children and elderly people, and in patients whose conditions may be aggravated by muscarinic blockade (e.g., asthma, urinary retention, open-angle glaucoma, hypertension, prostatic hyperplasia). The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines. Additional side effects include nervousness, tremors, dizziness, dry mouth, palpitations, anorexia, nausea, and vomiting.

A patient comes to the clinic with pruritus and nasal congestion after eating shrimp for lunch. The nurse is aware that the patient may be having an anaphylactic reaction to the shrimp. These symptoms typically occur within how many hours after exposure?

2 hours Explanation: Mild systemic, anaphylactic reactions consist of peripheral tingling and a sensation of warmth, possibly accompanied by a sensation of fullness in the mouth and throat. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes can also be expected. Onset of symptoms begins within the first 2 hours after exposure.

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time?

6 weeks Explanation: Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels.

A client with AIDS has become forgetful with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?

AIDS dementia complex (ADC) Explanation: ADC, a neurologic condition, causes the degeneration of the brain, especially in areas that affect mood, cognition, and motor functions. Such clients exhibit forgetfulness, limited attention span, decreased ability to concentrate, and delusional thinking. DSP is characterized by abnormal sensations, such as burning and numbness in the feet and later in the hands. Candidiasis is a yeast infection that may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in the folds of the skin. CMV infects the choroid and retinal layers of the eye, leading to blindness, and can also cause ulcers in the esophagus, colitis, diarrhea, pneumonia, and encephalitis.

A client is given a dose of ketorolac, a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor. What priority measure should the nurse prepare to do?

Administer epinephrine. Explanation: Anaphylaxis is a rapid and profound type I hypersensitivity response. A massive release of histamine causes vasodilation; increased capillary permeability; angioneurotic edema (acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs); hypotension; and bronchoconstriction. A nurse must administer 0.2 mg of epinephrine subcutaneously to a client experiencing a severe allergic reaction. It is outside of the nurse's practice to intubate a client. Performing an ECG and assessing the vital signs delays the treatment of the client and can have negative outcomes.

The nurse is teaching a client after a medication allergic reaction has occurred. What is the most important action for the nurse to teach the client to take to prevent anaphylaxis?

Avoid potential allergens. Explanation: Strict avoidance of potential allergens is the most important preventive measure for the patient at risk for anaphylaxis. People who have experienced food, medication, idiopathic, or exercise-induced anaphylactic reactions should always carry an emergency kit containing epinephrine for injection to prevent the onset of the reaction upon exposure, but avoiding potential allergens is more important. Desensitization, based on controlled anaphylaxis with a gradual release of mediators, is an effective treatment option, but it is more important to avoid allergic triggers. The medical alert bracelet will assist those rendering aid to the patient who has experienced an anaphylactic reaction, but it's better to avoid the reaction in the first place.

Which of the following cell types are involved in humoral immunity?

B lymphocytes Explanation: B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.

A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. What manifestation would the nurse most likely exhibit?

Blistering Explanation: Manifestations associated with allergic contact dermatitis related to latex include blisters, pruritus, erythema, swelling, and crusting or other skin lesions. Laryngeal edema, rhinitis, and angioedema would be noted with a latex allergy.

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?

Bone marrow transplantation Explanation: Treatment options for SCID include stem cell and bone marrow transplantation.

The nurse is evaluating the plan of care for a client with an allergic disorder who has a nursing diagnosis of deficient knowledge related to measures for allergy control. What client statement will indicate to the nurse that the outcome has been met?

Client identifies methods for reducing exposure risk to allergens. Explanation: For the nursing diagnosis of deficient knowledge, the client's ability to identify methods for reducing the risk of allergen exposure indicates that the outcome has been met. The statement about coughing and deep breathing and an absence of symptoms would be appropriate for evaluating the nursing diagnosis of ineffective breathing pattern. Positive coping strategies would be an appropriate outcome for a nursing diagnosis of ineffective coping.

More than 50% of individuals with this disease develop pernicious anemia:

Common variable immunodeficiency (CVID) Explanation: More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions.

The nurse is obtaining the medical history of a client with Crohn's disease. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response?

Corticosteroids Explanation: The nurse obtains a history of immunizations, recent and past infectious diseases, and recent exposure to infectious diseases. The nurse reviews the client's drug history because certain drugs, such as corticosteroids, suppress the inflammatory and immune responses. Nonsteroidal anti-inflammatory medication does not suppress the inflammatory and immune responses of Crohn's disease. An ACE-I prevents the conversion of angiotensin I to angiotensin II and does not suppress the inflammatory or immune response. Diuretics also do not suppress the immune response but help reduce excess fluid from the kidneys.

The nurse is caring for a client with myasthenia gravis. The nurse generates a plan of care for the client based on which type of hypersensitivity reaction?

Cytotoxic Explanation: Cytotoxic hypersensitivity occurs when the body mistakenly identifies a part of the body as foreign, as in myasthenia gravis, where the body mistakenly identifies normal nerve endings as foreign. Delayed hypersensitivity reactions occur 24 to 72 hours after exposure. Immune complex hypersensitivity involves immune complexes formed when antigens bind to antibodies. Anaphylactic hypersensitivity is an immediate reaction characterized by edema in many tissues, often with hypotension, bronchospasm, and cardiovascular collapse.

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.

Cytotoxic T cell Explanation: The cytotoxic T cells (also known as killer T cells) attack the antigen directly and release cytotoxic enzymes and cytokines.

A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about?

Desensitization Explanation: Desensitization is another option. Desensitization is a form of immunotherapy in which a person receives weekly or twice-weekly injections of dilute but increasingly higher concentrations of an allergen without interruption. SLIT is a form of desensitization therapy. Options C and D are distractors for this question.

The nurse working in an allergy clinic is preparing to administer skin testing to a client. Which route is the safest for the nurse to use to administer the solution?

Intradermal Explanation: The intradermal route is the correct route of administration for skin testing and therefore a safe route. Another safe route is epicutaneous. The type of skin testing being performed determines whether the nurse will administer the solution via the epicutaneous or intradermal route.

A patient presents to a clinic on May 1 and tells the nurse practitioner that he had a 1-month sexual relationship with a friend who did not disclose that he was HIV positive. The relationship ended last week. The nurse tells the patient that after infection with HIV, the immune system responds by making antibodies against the virus; therefore the patient should expect this to happen by:

June 5 Explanation: An antibody response to an HIV infection usually occurs 4 to 6 weeks after exposure.

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 Explanation: Macrophages move toward the antigen and destroy it. Eosinophils are only slightly phagocytic.

A client with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this client?

Meticulous infection control precautions Explanation: Nursing care must be meticulous. Appropriate infection control precautions and thorough hand hygiene are essential. Institutional policies and procedures related to protective care must be followed scrupulously until definitive evidence demonstrates that precautions are unnecessary. Continual monitoring of the patient's condition is critical, so early signs of impending infection may be detected and treated before they seriously compromise the patient's status. It also is imperative that nurses appropriately apply standard precautions (previously known as universal precautions), which have become one of the first-line tools for decreasing transmission of disease.

A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?

Natural immunity Explanation: Natural immunity, which is nonspecific, provides a broad spectrum of defense against and resistance to infection. It is considered the first line of host defense following antigen exposure, because it protects the host without remembering prior contact with an infectious agent.

A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles?

Phagocytosis Explanation: During the first mechanism of defense, white blood cells, which have the ability to ingest foreign particles, move to the point of attack, where they engulf and destroy the invading agents. This is known as phagocytosis. The action described is not apoptosis (programmed cell death) or an antibody response. Phagocytosis occurs in the context of the cellular immune response, but it does not constitute the entire cellular response.

Which intervention is the single most important aspect for the client at risk for anaphylaxis?

Prevention Explanation: Prevention involves strict avoidance of potential allergens for the individual at risk for anaphylaxis. If avoidance of or exposure to allergens is impossible then the individual should be prepared with an emergency kit containing epinephrine for injection to prevent the onset of the reaction upon exposure. While helpful, there must be no lapses in desensitization therapy because this may lead to the reappearance of an allergic reaction when the medication is reinstituted. A medical alert bracelet will assist those rendering aid to a client who has experienced an anaphylactic reaction. antihistamines may not be effective in preventing anaphylaxis.

An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred?

Rh-hemolytic disease Explanation: A type II hypersensitivity, or cytotoxic, reaction, which involves binding either the IgG or IgM antibody to a cell-bound antigen, may lead to eventual cell and tissue damage. The reaction is the result of mistaken identity when the system identifies a normal constituent of the body as foreign and activates the complement cascade. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia.

A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines?

Sedation Explanation: Antihistamines are the major class of medications prescribed for the symptomatic relief of allergic rhinitis. The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines.

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

T-cell lymphocytes survey proteins in the body and attack the invading antigens. Explanation: During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their toxins through agglutination or by causing them to precipitate.

A client taking fosamprenavir reports "getting fat." What is the nurse's best action?

Teach the client about medication side effects. Explanation: The client needs to be aware of the potential for fat redistribution. Exercise, diet, and counseling will not change the outcome of this side effect.

A nurse is visiting the home of a client with AIDS who is experiencing HIV encephalopathy. When developing the plan of care for the client and his caregiver, the nurse identifies the nursing diagnosis of disturbed thought processes related to confusion and disorientation secondary to HIV encephalopathy. Which expected outcome would be most appropriate for the nurse to document on the client's plan of care?

The client can state that he is at his home. Explanation: The most appropriate outcome for the nursing diagnosis would be that the client can state that he is in his home, which indicates that he is aware of his surroundings and location. Remaining free of injury when out of bed would be appropriate if the nursing diagnosis was risk for injury. Nodding by the client may or may not indicate that the client understands instructions. Although engaging in diversional activities would help the client focus, it would be a more appropriate outcome for social isolation or deficient diversional activity.

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 Explanation: The nurse needs to review the client's drug history. This data will help to assess the client's susceptibility to illness because certain past illnesses and drugs, such as corticosteroids, suppress the inflammatory and immune responses. The client's age, home environment, and diet do not have any major implications during assessment because they do not indicate susceptibility to illness.

A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits what behavior?

The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. Explanation: Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same client. Each of the other listed actions adheres to standard precautions.

What education should the nurse provide to the patient taking long-term corticosteroids?

The patient should not stop taking the medication abruptly and should be weaned off of the medication. Explanation: Patients who receive high-dose or long-term corticosteroid therapy must be cautioned not to stop taking the medication suddenly. Doses are tapered when discontinuing this medication to avoid adrenal insufficiency.

A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?

Trimethoprim-sulfamethoxazole Explanation: To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat candidiasis.

A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?

type I Explanation: There are four types of hypersensitivity responses, three of which are immediate. This is an example of Type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies.

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." Explanation: The client requires further teaching if the client states, "I will gargle to help alleviate tingling in the lips or mouth." Allergy testing introduces potentially irritating substances to the client. Tingling in the mouth, lips, or throat indicates the onset of a severe reaction and the need for immediate medical intervention. The testing may cause irritation and itching at the test site. The health care provider may order an epinephrine pen (EpiPen) for the client to self-administer epinephrine if the client experiences an allergic reaction away from the office setting.

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." Explanation: An allergic disorder is characterized by a hyperimmune response to weak antigens that usually are harmless. The antigens that can cause an allergic response are called allergens.

A client with an autoimmune disorder asks, "Why is autoimmune disease more prevalent in the women in my family?" Which response will the nurse make to this client?

"It's believed to be caused by the differences in the sex hormones." Explanation: There are differences in the immune system functions of men and women. Research has revealed that sex hormones are integral signaling modulators of the immune system and the presence of autoimmune disease. Sex hormones play definitive roles in lymphocyte maturation, activation, and synthesis of antibodies and cytokines. Even though some autoimmune diseases are genetically linked, overall men do not have stronger genes than women. There is no evidence that the client relinquishes self-care for family care. Even though stress influences immunity, there is no evidence that women have more stress than men.

A patient was seen in the clinic 3 days previously for allergic rhinitis and was given a prescription for a corticosteroid nasal spray. The patient calls the clinic and tells the nurse that the nasal spray is not working. What is the best response by the nurse?

"The full benefit of the medication may take up to 2 weeks to be achieved." Explanation: Patients must be aware that full benefit of corticosteroid nasal sprays may not be achieved for several days to 2 weeks.

A nurse is teaching the parents of an infant about primary immunodeficiencies. Which statement verifies that the parents understand the teaching?

"The majority of primary immunodeficiencies are diagnosed in infancy." Explanation: The majority of primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1.

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

Antineoplastic drug therapy Explanation: Clients who receive chemotherapy are immunosuppressed. Antineoplastic drugs cause a compromised immune system. Breast cancer is not associated with an excess of lymphocytes, a deficiency of circulating antibodies, or an excess of hemoglobin.

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 Explanation: Ataxia should be assessed when suspecting immune dysfunction in the neurosensory system. Joint movement, a urinalysis results positive for hematuria , and measuring abdominal girth are not used to assess for issues with the neurosensory system in relation to immune dysfunction.

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?

Ataxia Explanation: Ataxia should be assessed when immune dysfunction in the neurosensory system is suspected. Hematuria, discharge, and frequency of and burning upon urination are associated with the genitourinary system.

The client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?

Avoid antihistamines and cold preparations for 48 to 72 hours before the test. Explanation: The nurse should instruct the client to avoid taking prescribed or over-the-counter antihistamine or cold preparations for at least 48 to 72 hours before a skin test because this reduces the potential for false-negative test results. The nurse should not ask the client to avoid red meat, strenuous physical activity, or sunlight because these do not affect the test results.

A client calls the clinic and asks the nurse if using oxymetazoline nasal spray would be all right to relieve the nasal congestion the client is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications?

Do not overuse the medication as rebound congestion can occur. Explanation: Overusing oxymetazoline nasal spray can cause rebound congestion. The medication does not cause fungal infection. Corticosteroids should be tapered, but it is not necessary to taper oxymetazoline. Oxymetazoline does not cause sleepiness so the client can operate machinery or drive.

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

For their immunosuppressant effects Explanation: Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just so the client has strong drug therapy.

Which term refers to an incomplete antigen?

Hapten Explanation: A hapten is an incomplete antigen. An allergen is a substance that causes manifestations of allergy. An antigen is a substance that induces the production of antibodies. An antibody is a protein substance developed by the body in response to and interacting with a specific antigen.

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

Naturally acquired active immunity Explanation: Naturally acquired active immunity occurs as a result of an infection by a specific microorganism. Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid. Passive immunity develops when ready-made antibodies are given to a susceptible individual.

A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"?

Only use the nasal spray for 3 to 4 days once every 12 hours. Explanation: Adrenergic agents, which are vasoconstrictors of mucosal vessels, are used topically in nasal (oxymetazoline [Afrin]) and ophthalmic (brimonidine [Alphagan P]) formulations in addition to the oral route (pseudoephedrine [Sudafed]). The topical route (drops and sprays) causes fewer side effects than oral administration; however, the use of drops and sprays should be limited to a few days to avoid rebound congestion.

What severe complication does the nurse monitor for in a patient with ataxia-telangiectasia?

Overwhelming infection Explanation: Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular lesions caused by dilated blood vessels), and immune deficiency. The immunologic defects reflect abnormalities of the thymus. The disorder is characterized by some degree of T-cell deficiency, which becomes more severe with advancing age. Immunodeficiency is manifested by recurrent and chronic sinus and pulmonary infections, leading to bronchiectasis.

A client taking abacavir has developed fever and rash. What is the priority nursing action?

Report to the health care provider. Explanation: Fever and a rash could be indicative of a hypersensitivity reaction. Hypersensitivity reactions are also known as anaphylactic reactions and often involve skin rashes, fever, and bronchopulmonary issues such as bronchial constriction. The health care provider should be notified immediately and the medication stopped. Interventions need to be taken to assure that the client's airway is not compromised. Administering acetaminophen and documentation and treating the rash are not the priority and would be completed after the client is stabilized.

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?

Respiratory or urinary system infections Explanation: Secondary immunodeficiencies occur as a result of underlying disease processes or the treatment of these disorders, including administration of immunosuppressive agents. Abnormalities of the immune system affect both natural and acquired immunity. Because immunodeficiencies result in a compromised immune system and pose a high risk for infection, careful assessment of the client's immune status is essential. The nurse assesses and monitors the client for signs and symptoms of infection.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Risk for injury Explanation: In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.

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. Explanation: The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Stem cells comprise only a small portion of all types of bone marrow cells. Research conducted with mouse models has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in human subjects with certain types of immune dysfunction, such as severe combined immunodeficiency. Clinical trails are underway in clients with a variety of disorders with an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis.

Kaposi sarcoma (KS) is diagnosed through

biopsy. Explanation: KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count.

A client visits the employee health department because of mild itching and a rash on both hands. What will the employee health nurse focus on during the assessment interview?

chemical and latex glove use Explanation: Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 33: Assessment and Management of Patients with Allergic Disorders, ALLERGIC DISORDERS, Latex Allergy, p. 1062.

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. semen urine breast milk blood vaginal secretions

semen breast milk blood vaginal secretions Explanation: There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.

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." Explanation: Research has shown that stem cells can restore an immune system that has been destroyed (Ko, 2012). Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, such as severe combined immunodeficiency; clinical trials using stem cells are underway in clients with a variety of disorders having an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis. Research with embryonic stem cells has enabled investigators to make substantial gains in developmental biology, gene therapy, therapeutic tissue engineering, and the treatment of a variety of diseases (Ko, 2012). However, along with these remarkable opportunities, many ethical challenges arise, which are largely based on concerns about safety, efficacy, resource allocation, and human cloning.

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likely expect to find irritation at which area?

Dorsal aspect of the hand Explanation: With allergic contact dermatitis, irritation is most common on the dorsal aspects of the hand. Irritant, phototoxic, and photoallergic types of contact dermatitis are commonly seen on the hands and lower arms.

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses?

Immunosenescence Explanation: Immunosenescence is the term for age-related changes in the immune system. These changes have been linked to the increased rates of illness and mortality in older adults, and an increased incidence of infections. There is no evidence that polypharmacy has caused an increase in infections in the older adult. The development of infections is not directly linked to vitamin intake or self-care activities.

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 Explanation: Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. Loss of serum or plasma does not deplete the body of catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas).

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 Explanation: Removal of the appendix would have no direct effect on the immune system. Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Radiation therapy destroys lymphocytes. The spleen is an important part of the immune system, and removal of it increases the client's risk for poor immune function.

The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction?

Symptoms are localized to the area of exposure, usually the back of the hands. Explanation: Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. When clinical manifestations occur within minutes after exposure to latex, which is described as a latex allergy, an immediate hypersensitivity (type I) allergic reaction has occurred.

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. Explanation: The injection area swells if the client has developed antibodies against the antigen. The client is not necessarily actively infectious if the test results are positive. Although a productive cough is one of the symptoms of active tuberculosis, it may also indicate other diseases and disorders. The area should not be painful, and the client should not break out with a rash.

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:

Western blot test for confirmation of diagnosis. Explanation: The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.

The nurse is caring for a client exposed to peanuts with a known allergy. What assessment is considered the most serious manifestation of angioneurotic edema?

laryngeal swelling Explanation: Diffuse swelling can affect many regions: lips, eyelids, cheeks, hands, feet, genitalia, tongue, larynx, bronchi, and the gastrointestinal canal. The most serious is the larynx because of the potential for compromised breathing. Abdominal pain, conjunctivitis and urticaria are not the most serious manifestations.

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

naturally acquired active immunity Explanation: Naturally acquired active immunity occurs as a direct result of an infection by a specific microorganism.

The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response?

plant pollen Explanation: Plant pollen (from trees, grass, and other plants) causes the most common form of allergic rhinitis, which is known as hay fever. Animal dander, dust mites, and mold spores can be triggers, but are not the most common causes.

The nurse tells the client that if exposure to an allergen occurs around 8:00 AM, then the client should expect a mild or moderate reaction by what time?

10:00 AM Explanation: Mild and moderate reactions begin within 2 hours of exposure.

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment?

Dyspnea, bronchospasm, and/or laryngeal edema. Explanation: Severe systemic, anaphylactic reactions have an abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

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 Explanation: It is the nurse's role to counsel, educate, and support clients throughout the diagnostic process. Many clients may be extremely anxious about the results of diagnostic tests and the possible implications of those results for their employment, insurance, and personal relationships. This is an ideal time for the nurse to provide counseling and education.

A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection?

Follow the same sexual precautions as someone who has been diagnosed with AIDS. Explanation: The healthcare worker will be tested for HIV at regular intervals and treated with antiretrovirals depending on the results of the tests or the potential for infection. While awaiting the results, the healthcare worker should follow the same sexual precautions as someone who has been diagnosed with AIDS. The healthcare worker should not limit interactions with either non-HIV-infected or HIV-infected people. In addition, the healthcare worker should not quit and be admitted to a hospital for treatment. Treatment, if required, can begin if the result of the test is positive.

Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle?

Histamine Explanation: When cells are damaged, histamine is released. Bradykinin is a polypeptide that stimulates nerve fibers and causes pain. Serotonin is a chemical mediator that acts as a potent vasoconstrictor and bronchoconstrictor. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activities.

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 Explanation: Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific micro organism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid.

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 become enlarged (splenomegaly) in certain hematologic disorders and cancers. To assess an enlarged spleen, the nurse would palpate the area of the:

Upper left quadrant of the abdomen. Explanation: The spleen is located to the left of the stomach, in the upper left of the abdomen. It plays an important role in the immune system.

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse knows which body fluid is not a means of transmission?

Urine Explanation: HIV is transmitted in body fluids that contain free virions and infected CD4+ T cells. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. Urine is not a body fluid responsible for HIV transmission.

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 Explanation: Interferons are chemicals that primarily protect cells from viral invasion. They enable cells to resist viral infection and slow viral replication. They have been used as adjunctive therapy in the treatment of AIDS. Interferons also have been used to treat some forms of cancer such as leukemia because they stimulate NK cell activity. Interferon is administered parenterally because digestive enzymes destroy its protein structure.