Adult Health Chapter 36: Nursing Assessment: Immune Function 1
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."
A client is informed of having a low white blood cell count and that the client is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse?
"White blood cells are produced in the bone marrow."
Which of the following cell types are involved in humoral immunity?
B lymphocytes
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?
Lymphoid tissues
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?
Natural immunity
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
T-cell deficiency occurs when which gland fails to develop normally during embryogenesis?
Thymus
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."
During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess?
Acquired immunity
A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client?
Assure the client that this is a normal reaction
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?
Bone marrow suppression
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse of having several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications?
Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.
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
An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated?
Cytotoxic T cells
A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used?
Digestive enzymes destroy its protein structure.
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
A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?
For their immunosuppressant effects
Which of the following protective responses begin with the B lymphocytes?
Humoral
The nurse practitioner explains to the patient scheduled for the RAST that the test will measure allergen-specific __________.
Ig E
When the body is in contact with an allergen, this lymphocyte, located in the respiratory and intestinal mucosa, triggers the release of histamine. Choose that lymphocyte.
Ig E
What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction?
IgE
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?
Lymphocyte
A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact her bone marrow is unable to produce a sufficient amount of what?
Lymphocytes
A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby:
Lymphocytes migrate to areas of the lymph node
A child is brought to the clinic with a rash and is subsequently diagnosed with measles. The parent reports also having had measles as a young child. What type of immunity to measles develops after the initial infection?
Naturally acquired active immunity
Which type of immunity becomes active as a result of infection by a specific microorganism?
Naturally acquired active immunity
The nurse is preparing an educational tool on the importance of nutrition and the immune system. The nurse will educate clients about the ability of which types of foods to boost immune function? Select all that apply.
Organ meats Beans
Which condition is associated with impaired immunity relating to the aging client?
Renal function decreases
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
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.
During an annual examination, an older client tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel just fine!" Based on knowledge of neoplastic disease and the aging immune system, what teaching should the nurse include in the client's plan of care? Select all that apply.
Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes; therefore the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early. The increase in occurrence of autoimmune diseases with aging strongly suggests a predisposition toward various types of cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of finding and treating cancer early. Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development.
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.
Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that:
filter bacteria from tissue fluid.
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.
Which is an action of cytotoxic T cells?
Lyse cells infected with virus
Which type of cell is capable of directly killing invading organisms and producing cytokines?
Natural killer cells
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
Programs T lymphocytes to become regulator or effector T cells
What is the function of the thymus gland?
Programs T lymphocytes to become regulator or effector T cells
A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder?
The immune system recognizes one's own tissues as "foreign."
A 48-year-old patient has had multiple sclerosis for 15 years, and she is receiving interferon injections. What is the purpose of interferon injections?
To modify the immune response by suppressing antibody production and cellular immunity
Which allergic reaction is potentially life threatening?
angioedema
What types of cells are the primary targets of the healthy immune system? Select all that apply.
infectious cells foreign cells cancerous cells
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
neutrophils and monocytes.
A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit?
type I
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?
Artificially acquired active immunity
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
