Chapt. 31, 32, 33 Immune System (Prep U)
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.
The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply.
The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle. Explanation: The CD4 count is the major indicator of immune function. Antiretroviral therapy in HIV targets different stages of the HIV life cycle. Therapy does not prevent opportunistic infections. Medication therapy is effective, and most clients respond well to it.
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.
There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency.
"Your immune system was most likely affected by an underlying disease process." Explanation: A secondary immunodeficiency is the result of an underlying disease process or the treatment of a disorder. It is not genetically inherited. Some examples of a secondary immunodeficiency are chronic stress and diabetes mellitus.
The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed?
"I will be sure to eat lots of fresh fruits and vegetables every day." Explanation: The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.
Which response is a humoral immune response?
Anaphylaxis Explanation: Anaphylaxis is an example of a humoral response. Cellular responses include transplant rejection, intracellular infections, and delayed hypersensitivity.
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.
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.
Which is usually the most important consideration in the decision to initiate antiretroviral therapy?
CD4+ counts Explanation: The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts.
A patient who suffered severe partial thickness burns to the face and trunk is at risk for depletion of essential proteins and immunoglobulins. The stressors associated with this patient's major injury have caused what immune process to occur?
Cortisol is released from the adrenal cortex, which contributes to immunosuppression. 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. The physiologic and psychological stressors associated with surgery or injury stimulate cortisol release from the adrenal cortex; increased serum cortisol also contributes to suppression of normal immune responses (Jeckel, Lopes, Berleze, et al., 2010).
Which microorganism is known to cause retinitis in people with HIV/AIDS?
Cytomegalovirus Explanation: Cytomegalovirus is a species-specific herpes virus. C. neoformans is a fungus that causes an opportunistic infection in clients with HIV/AIDS. M. avium is an acid-fast bacillus that commonly causes a respiratory illness. P. carinii is an organism that is thought to be protozoan, but believed to be a fungus based on its structure.
A nurse is preparing to administer an antiretroviral medication to a client who is positive for HIV. The nurse identifies the drug as a nucleoside reverse transcriptase inhibitor (NRTI). What drug will the nurse administer?
Lamivudine Explanation: Lamivudine (Epivir) is an antiretroviral agent that belongs to the class of NRTIs. Delavirdine (Rescriptor), etravirine (Intelence), and nevirapine (Viramune) are examples of non-nucleoside reverse transcriptase inhibitors (NNRTIs).
The nurse teaches the client that reducing the viral load will have what effect?
Longer survival Explanation: The lower the client's viral load, the longer the survival time and the longer the time to AIDS diagnosis.
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 Explanation: Recognition of antigens as foreign, or non-self, by the immune system is the initiating event in any immune response. Recognition involves the use of lymph nodes and lymphocytes for surveillance. Lymph nodes are widely distributed internally throughout the body and in the circulating blood, as well as externally near the body's surfaces. They continuously discharge small lymphocytes into the bloodstream. These lymphocytes patrol the tissues and vessels that drain the areas served by that node.
The nursing instructor is discussing the development of human immunodeficiency disease (HIV) with the students. What should the instructor inform the class about helper T cells?
They are activated on recognition of antigens and stimulate the rest of the immune system. Explanation: Helper T cells are activated on recognition of antigens and stimulate the rest of the immune system.
A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection?
Through the mucous membranes of the throat Explanation: In a streptococcal throat infection, the streptococcal organism gains access to the mucous membranes of the throat.
A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client 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.
When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following?
Antibodies to HIV are not present in his blood. Explanation: A negative test result indicates that antibodies to HIV are not present in the blood at the time the blood sample for the test is drawn. A negative test result should be interpreted as demonstrating that if infected, the body has not produced antibodies (which take from 3 weeks to 6 months or longer). Therefore, subsequent testing of an at-risk patient must be encouraged. The test result does not mean that the patient is immune to the virus, nor does it mean that the patient is not infected. It just means that the body may not have produced antibodies yet. When antibodies to HIV are detected in the blood, the test is interpreted as positive.
The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care?
Assist with chest physiotherapy every 2 to 4 hours. Explanation: The nurse should include interventions such as assisting with and/or performing chest physiotherapy every 2 to 4 hours to prevent stasis of secretions, assist the client to attain the semi- or high Fowler's position to facilitate breathing and airway clearance, allow for frequent rest periods to prevent excessive fatigue, and maintain a fluid intake of at least 3 liters per day unless contraindicated.
A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses, including the steps in the process of HIV entering the host cell. What would the nurse describe as the first step?
Attachment Explanation: Once HIV enters the host cell, attachment occurs in which the glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors. This is followed by uncoating, in which HIV's viral core is emptied into the CD4+ T cell. Cleavage and budding occur as the last steps.
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 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.
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material?
Ribonucleic acid (RNA) Explanation: HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins.
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.
A client with AIDS develops pneumocystis pneumonia. The nurse would most likely expect to include administration of which agent in the client's plan of care?
TMP-SMZ Explanation: TMP-SMZ is the treatment of choice for pneumocystis pneumonia. Alternative regimens may include dapsone and TMP, primaquine plus clindamycin, or atovaquone suspension. Aerosolized pentamidine is not used because of its limited efficacy and more frequent cases of relapse. Azithromycin or clarithromycin are the preferred prophylactic agents for Mycobacterium avium complex.
A nurse is preparing a presentation about human immunodeficiency virus (HIV) for a local community group. What would the nurse include in the presentation about HIV transmission? Select all that apply.
The risk of acquiring HIV through the transfusion of blood products is almost nonexistent. The amount of HIV contained in body fluids on exposure is associated with the risk for infection. HIV can be found in seminal fluid, vaginal secretions, and breast milk. Sharing of infected equipment used to inject drugs increases the risk for infection. Explanation: HIV-1 is transmitted in body fluids that contain free virions and infected CD+4 T cells. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. The amount of HIV and infected cells in the body fluid is associated with the probability that the exposure will result in infection. Blood and blood products can transmit HIV to recipients; however, the risk associated with transfusions have been virtually eliminated as the result of intensive donor screening. Mother-to-child transmission may occur in utero, at the time of delivery, or through breastfeeding. Most perinatal infections are thought to occur during delivery. Sharing infected equipment during drug injections increases a person's risk for acquiring HIV.
Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?
Vascular lesions Explanation: Ataxia-telangiectasis is characterized by loss of muscle coordination and vascular lesions. Thrombocytopenia and eczema are associated with Wiskott-Aldrich syndrome. Thrush is a manifestation associated with severe combined immunodeficiency (SCID).
The nurse reviews laboratory results requested to track HIV. What laboratory test measures HIV RNA levels and is the best predictor of HIV disease progression?
Viral load Explanation: The viral load test quantifies the plasma HIV RNA levels and response to treatment of the HIV infection. It also confirms a positive EIA result and detects HIV in high-risk seronegative individuals before antibodies are measurable.
What test will the nurse assess to determine the client's response to antiretroviral therapy?
Viral load Explanation: 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. The other tests are not used in this way.
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 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 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 teaching a client with immunodeficiency about the signs and symptoms of infection to report. The nurse determines that the teaching was successful when the client makes which statement?
"Any change, however subtle, might mean that I have an infection." Explanation: For clients with immunodeficiencies, subtle changes may indicate an infection. Therefore, the client would contact the health care provider if symptoms develop that are not typical. Fever does not need to be over 101 degrees to indicate an infection. A cough, either dry or wet, or swollen lymph nodes suggest infection.
A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client?
"Be sure to take this drug about 1/2 hour before or 2 hours after you eat." Explanation: Didanosine (Videx) should be taken 30 to 60 minutes before or 2 hours after meals. Other antiretroviral agents, such as abacavir, emtricitabine, or lamivudine can be taken without regard to meals. High-fat meals should be avoided when taking amprenavir. Atazanavir should be taken with food and not with antacids.
A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which statement?
"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling." Explanation: Treatment options for SCID include stem cell and bone marrow transplantation. Hematopoietic stem cell transplantation is the definitive therapy for SCID; the best outcome is achieved if the disease is recognized and treated early in life. The ideal donor is a human leukocyte antigen-identical sibling.
A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action?
Assess blood urea nitrogen and creatinine. Explanation: Adverse effects associated with antiretroviral therapy include potential nephrotoxicity. Assessing blood urea nitrogen and creatinine for clients who have decreased urination is appropriate. The other answers will not assist the nurse in determining the client's problem, which should be assessed before intervention are administered.
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 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.
A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen?
IV gamma globulin administration Explanation: Treatment for ataxia-telangiectasia includes IV gamma globulin, antimicrobial therapy, and bone marrow transplantation. It does not include platelet administration, factor VIII administration, or thymus grafting.
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.
A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect?
Pneumocystis jiroveci Explanation: Although mycobacterium, legionella, and cytomegalovirus may cause the signs and symptoms described, the most common infection in people with AIDS is pneumocystis pneumonia caused by pneumocystis jiroveci. It is the most common opportunistic infection associated with AIDS.
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?
Stool specimen for ova and parasites Explanation: A stool specimen for ova and parasites will give a definitive diagnosis. The organism is spread by the fecal-oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude of fluid quickly leads to dehydration and electrolyte imbalances.
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.
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.
The lower the client's viral load,
the longer the survival time. Explanation: The lower the client's viral load, the longer the time to AIDS diagnosis and the longer the survival time. The key goal of antiretroviral therapy is to achieve and maintain durable viral suppression.
Ibuprofen affects the immune system by causing
neutropenia. Explanation: Ibuprofen causes leukopenia and neutropenia. Phenylbutazone causes pancytopenia. Cefuroxime sodium causes thrombocytopenia and hemolytic anemia.
When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask?
"Have you ever received a blood transfusion?" Explanation: A history of blood transfusions is obtained, because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function.
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." Explanation: White blood cells (leukocytes) are produced in the bone marrow. They are not produced in the plasma, thymus gland, or the lymphatic tissue.
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.
Which of the following is a age-related change associated with the immune system?
Decreased antibody production Explanation: Age-related changes associated with the immune response include decreased antibody production, suppressed phagocytic immune response, and a failure of immune system to differentiate "self" from "nonself."
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. Explanation: Interferon is administered parenterally because digestive enzymes destroy its protein structure. The medicine does not have an oral preparation.
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.
What does the nurse understand will result if the patient has a deficiency in the normal level of complement?
Increased susceptibility to infection Explanation: The complement system is an integral part of the immune system, and deficiencies in normal levels of complement result in increased susceptibility to infectious diseases and immune-mediated disorders.
Which type of cells destroys antigens already coated with antibody?
Null Explanation: Null cells destroy antigens already coated with antibody. NK cells defend against microorganisms and some types of malignant cells. Memory T cells remember contact with an antigen and, on subsequent exposures, mount an immune response. Suppressor T-cells suppress the immune response.
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.
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 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.
The nurse is instructing clients about the importance of taking the shingles vaccine. Which client would benefit from this vaccine?
A 65-year-old client who had chicken pox when he was 12 years old Explanation: Half of individuals living to age 65 years have had or will develop shingles and may not understand the potential seriousness and risk for complications. Nurses as client advocates should determine and provide health information regarding the shingles vaccine. The other clients are not candidates for the vaccine
Which condition is associated with impaired immunity relating to the aging client?
Breakdown and thinning of the skin Explanation: The aging process stimulates changes in the immune system. Age-related changes in many body systems also contribute to impaired immunity. Changes such as poor circulation, as well as the breakdown of natural mechanical barriers such as the skin, place the aging immune system at even greater disadvantage against infection. As the immune system undergoes age-associated alterations, its response to infections progressively deteriorates. Humoral immunity declines and the number of inflammatory cytokines increase with age.
Nursing students are reviewing information about the various types of primary immunodeficiencies. The students demonstrate understanding of the material when they identify which of the following as an example of a primary immunodeficiency involving B-lymphocyte dysfunction?
CVID Explanation: CVID is an example of B-cell deficiency that results from a lack of differentiation of B cells into plasma cells. Ataxia-telangiectasia and Wiskott-Aldrich syndrome are examples of combined B- and T-lymphocyte dysfunction. Hyperimmunoglobulin E syndrome is an example of a primary immunodeficiency involving platelet dysfunction.
While caring for a patient with pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate?
Kaposi's sarcoma Explanation: Kaposi's sarcoma, the most common HIV-related malignancy, is a disease that involves the endothelial layer of blood and lymphatic vessels. Cutaneous signs may be the first manifestation of HIV; they can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymoses (hemorrhagic patches) and edema (Fig. 37-3).
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 Explanation: The immune system actually is a collection of specialized white blood cells and lymphoid tissues that cooperate to protect a person from external invaders and the body's own altered cells. The function of these structures is assisted and supported by the activities of natural killer cells, antibodies, and nonantibody proteins such as cytokines and the complement system. Red blood cells and stem cells are not part of the immune system.
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.
An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate wound healing and prevent poor outcomes for this client? Select all that apply.
Nutritional status Caloric intake Quality of food ingested Explanation: Nutritional intake that supports a competent immune response plays an important role in reducing the incidence of infections; clients whose nutritional status is compromised have a delayed postoperative recovery and often experience more severe infections and delayed wound healing. The nurse must assess the client's nutritional status, caloric intake, and quality of foods ingested.
The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function?
Previous organ transplantation Explanation: Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Removal of the appendix or stomach would have no effect on the immune system. A positive history for radiation therapy would affect the immune system, but not a negative history
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 has a suspected immune system disorder. What test would be ordered if a deficiency or excess of immunoglobulins was suspected?
Protein electrophoresis Explanation: When an immune system disorder is suspected, protein electrophoresis screens for diseases associated with a deficiency or excess of immunoglobulins may be ordered. Options B, C, and D are incorrect tests to diagnose a deficiency or excess of immunoglobulins.
A nurse is teaching a community group about healthy lifestyles. A participant asks about how to maintain a healthy immune system. The nurse informs the group that which factor will positively affect the immune system?
Strong family and community connections Explanation: Strong family and community ties will have a positive effect on the immune system. Rigorous or competitive exercise, usually considered a positive lifestyle factor, can be a physiologic stressor and cause negative effects on immune response. Any form of radiation can have a negative effect on the immune system, as can poor nutritional status.
The nurse is beginning the physical examination of a client with fatigue. What documentation will the nurse provide to describe this general appraisal of the client's health?
The client appears mildly ill, listless, and disheveled. Explanation: The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain vital signs and then performs a more comprehensive examination.
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." Explanation: The immune system's recognition of one's own tissues as "foreign" rather than self is the basis of many autoimmune disorders, including multiple sclerosis. When regulatory mechanisms fail to halt the immune response or excess cytokines are produced, pathology occurs (e.g., allergies, hypersensitivity).
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.
The nurse is reviewing the client's medications. What antihistamines are contraindicated for a client with narrow-angle glaucoma? Select all that apply.
diphenhydramine loratadine cetirizine brompheniramine Explanation: Diphenhydramine, loratadine, brompheniramine, and cetirizine are antihistamines contraindicated with clients with narrow-angle glaucoma. The antihistamines have the potential to induce angle closure. Fexofenadine should be used cautiously in patients with hepatic or renal impairment.
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 promotes inflammation, fever, and angiogenesis?
interleukins Explanation: Interleukins carry messages between leukocytes and tissues that form blood cells. Some interleukins enhance the immune response, whereas others suppress it (Martini & Bartholomew, 2016). Examples of interleukin activity include promotion of inflammation and fever, production of antibodies, and formation of new blood vessels (known as angiogenesis).
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. Explanation: Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy but still maintains responsibility for the medications administered.
A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which reason?
Exposure to foreign antigens may cause altered immune function. Explanation: A history of blood transfusions is obtained because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function. There is only a small risk for HIV transmission from transfusions received after 1985. The risk for exposure to hepatitis B from blood transfusions is extremely small.
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.
The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function?
Previous organ transplantation Explanation: Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Removal of the appendix or stomach would have no effect on the immune system. A positive history for radiation therapy would affect the immune system, but not a negative history.
A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?
The nurse ensures a written consent is obtained prior to testing. Explanation: The nurse ensures that a written consent is obtained before testing for human immunodeficiency virus (HIV) and keeps the results of HIV testing confidential. The client should never be tested without his knowledge. The physician will review the results when the client comes in for a follow-up visit. It is not necessary for the nurse to report results to the CDC.
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.
HIV is harbored within which type of cell?
Lymphocyte Explanation: Because HIV is harbored within lymphocytes, a type of white blood cell, any exposure to infected blood results in significant risk of infection. HIV infection is not harbored in platelets, erythrocytes, or nerve cells.
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.
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 promotes inflammation, fever, and angiogenesis?
interleukins Explanation: Interleukins carry messages between leukocytes and tissues that form blood cells. Some interleukins enhance the immune response, whereas others suppress it (Martini & Bartholomew, 2016). Examples of interleukin activity include promotion of inflammation and fever, production of antibodies, and formation of new blood vessels (known as angiogenesis).
A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which reason?
Exposure to foreign antigens may cause altered immune function. Explanation: A history of blood transfusions is obtained because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function. There is only a small risk for HIV transmission from transfusions received after 1985. The risk for exposure to hepatitis B from blood transfusions is extremely small.
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 Explanation: Immunity to measles that develops after the initial infection is an example of naturally acquired active immunity. Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated toxin), whereas passive immunity develops when ready-made antibodies are given to a susceptible client.
A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand?
Neutrophils Explanation: Neutrophils (polymorphonuclear leukocytes [PMNs]) are the first cells to arrive at the site where inflammation occurs. Eosinophils and basophils, other types of granulocytes, increase in number during allergic reactions and stress responses.
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. The other options are incorrect.
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 nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate?
candidiasis Explanation: Candidiasis is a yeast infection caused by the Candida albicans microorganisms. It may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in folds of the skin. It is often called thrush when located in the mouth. Inspection of the mouth, throat, or vagina reveals areas of white plaque that may bleed when mobilized with a cotton-tipped swab. Kaposi's sarcoma is a purple lesion and is an opportunistic cancer. Hairy leukoplakia is also an indication of oral cancer. Coccidioidomycosis causes diarrhea in the immunosuppressed client.
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
neutrophils and monocytes. Explanation: Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?
A cell-mediated response Explanation: A cell-mediated response occurs when T cells 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. An example of a cell-mediated response is one that occurs when an organ is transplanted. The complement system cooperates with antibodies to attract phagocytes and coat antigens to make them more recognizable for phagocytosis and stimulate inflammation and is not related to the surgery. Colony-stimulating factors prompt the bone marrow to produce, mature, and promote the functions of blood cells. Naturally acquired active immunity is a direct result of infection by a specific microorganism.
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.
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 Explanation: Immunity to measles that develops after the initial infection is an example of naturally acquired active immunity. Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated toxin), whereas passive immunity develops when ready-made antibodies are given to a susceptible client.
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. The other options are incorrect.
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 Explanation: IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reactions. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.
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 performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph nodes on the left. What should the nurse document? (Select all that apply.)
Location Size Consistency Reports of tenderness Explanation: The anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement; if palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Joints are assessed for tenderness, swelling, increased warmth, and limited range of motion.
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.
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.
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.
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.
An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect?
Naturally acquired active immunity Explanation: Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. 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. Passive immunity is acquired when ready-made antibodies are given to a susceptible person.
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 nurse is assessing a client with Kaposi's sarcoma. What initial sign does the nurse know to look for during assessment?
Deep purple cutaneous lesions Explanation: Localized cutaneous lesions may be the first manifestation of this HIV-related malignancy, which appears in 90% of clients as immune function deteriorates. Other symptoms develop over time as the lesions increase in size and spread to other locations.
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.
What types of cells are the primary targets of the healthy immune system? Select all that apply.
infectious cells foreign cells cancerous cells Explanation: The immune system's primary targets are infectious, foreign, or cancerous cells.
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.
A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers. What severe complication should the nurse be alert for with cytomegalovirus?
blindness Explanation: CMV can infect the choroid and retinal layers of the eye, leading to blindness. It does not lead to hearing impairment. Fatigue and diarrhea may occur but are not as critical as blindness.
A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?
AIDS Explanation: AIDS, the most common secondary disorder, is perhaps the best-known secondary immunodeficiency disorder. It results from infection with the human immunodeficiency virus (HIV). DAF refers to lysis of erythrocytes due to lack of decay-accelerating factor (DAF) on erythrocytes. CVID is a disorder that encompasses various defects ranging from IgA deficiency (in which only the plasma cells that produce IgA are absent) to severe hypogammaglobulinemia (in which there is a general lack of immunoglobulins in the blood). Severe combined immunodeficiency disease (SCID) is a disorder in which both B and T cells are missing.
During a 12-month well-baby visit, a mother reports that the baby has been breastfed since birth and has never been ill. The mother is trying to convince her sister, who is currently pregnant, to breastfeed also and asks the nurse about the benefits of breastfeeding. The nurse explains the immune benefits of breastfeeding and provides the mother with pamphlets. The nurse determines the mother understands the teaching based on which statement?
"Breastfeeding is beneficial because the dominant antibody IgA in breast milk acts by functioning as an antigen receptor in the mucosal membranes." Explanation: IgA composes 15% of total immunoglobulin. It appears in body fluids (blood, saliva, tears, breast milk, and pulmonary, gastrointestinal, prostatic, and vaginal secretions). It protects against respiratory, gastrointestinal, and genitourinary infections and passes to the neonate in breast milk for protection.
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.
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.
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.
The nurse is caring for an elderly client with a respiratory infection. While reviewing age-related changes in the immune system, the nurse identifies which factor as having contributed to this client's infection?
Impaired ciliary action as a result of exposure to environmental toxins Explanation: Impaired ciliary action from exposure to smoke and environmental toxins contributes to impaired clearance of pulmonary secretions and an increased incidence of respiratory infections in the elderly. Failure of immune system to differentiate "self" from "non-self" leads to an increased incidence of autoimmune diseases. Decreased phagocytosis by the liver's Kupffer cells leads to increased incidence and severity of hepatitis B. Decreased sensation and slowing of reflexes leads to increased risk of skin injury, skin ulcers, abrasions, burns, and other trauma.
A nurse is developing a teaching plan for a community presentation on smoking cessation. Based on current research regarding the effects of cigarette smoking on the immune system, which alterations in immune function can be attributed to smoking and should be included in the teaching presentation? Select all that apply.
Increased white blood cell count Decreased T-cell function Decreased natural killer cells Increased risk of infection Explanation: Smoking causes an increased white blood cell count (indicating inflammation), an elevated T-cell count (with decreased function), decreased antibody production (IgG, IgA, IgM), increased IgE (allergic response), and fewer natural killer cells (increased risk for infection) in the immune system.
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 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).
The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?
"The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." Explanation: A fungal infection, Cryptococcus neoformans is another common opportunistic infection among clients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures.
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.
When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic?
HIV-1 is more prevalent than HIV-2 subtypes Explanation: Two HIV subtypes have been identified: HIV-1 and HIV-2. HIV-1 mutates easily and frequently, producing multiple substrains that are identified by letters from A through O. HIV-2 is less transmittable, and the interval between initial infection with HIV-2 and development of AIDS is longer. HIV-1 is more prevalent in the United States and in the rest of the world. Western Africa is the primary site of infection with HIV-2. There is no cure for HIV/AIDS; hence, no cure rate. The virus is thought to be a mutation of a simian virus. Transmission of the virus is not a characteristic.
Which condition is an early manifestation of HIV encephalopathy?
Headache Explanation: Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.
A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, what would the nurse need to integrate into the presentation?
Most cases are typically diagnosed in infancy. Explanation: Most primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1. A large fraction of primary immunodeficiencies are not diagnosed until adolescence or early adulthood when the gender distribution equalizes. Secondary immunodeficiencies are more common than primary immunodeficiencies.
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.
Ataxia refers to
uncoordinated muscle movement. Explanation: Ataxia-telangiectasia is an autosomal recessive disorder affecting both T-cell and B-cell immunity. Telangiectasia refers to vascular lesions caused by dilated blood vessels. Receptive aphasia is an inability to understand spoken words. Dysphagia refers to difficulty swallowing.
When administering intravenous immunoglobulin (IVIG), what is the most important action for the nurse to take?
Premedicate the client with acetaminophen and diphenhydramine 30 minutes before starting. Explanation: When administering intravenous immunoglobulin (IVIG), the nurse should premedicate the client with acetaminophen and diphenhydramine 30 minutes before starting the infusion to prevent anaphylaxis and infuse IVIG at a rate of 3 mL/minute. The nurse needs to obtain the client's height and weight before treatment to verify that the dose is accurate. Checking the client's chart for height and weight would be inappropriate. The nurse also needs to assess the client for signs and symptoms of adverse effects, including flank and back pain, shaking chills, dyspnea, tightness in the chest, headache, fever, and local reactions at the infusion site. Complaints of a tickle or lump in the throat as the precursor to laryngospasm that precedes bronchospasm is a key warning sign of an anaphylactic reaction.
Which blood test confirms the presence of antibodies to HIV?
Enzyme immunoassay (EIA) Explanation: EIA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.
Which of the following indicates that a client with HIV has developed AIDS?
Herpes simplex ulcer persisting for 2 months Explanation: A diagnosis of AIDS cannot be made until the person with HIV meets case criteria established by the Centers for Disease Control and Prevention. The immune system becomes compromised. The CD4 T-cell count drops below 200 cells and develops one of the opportunistic diseases, such as Pneumocystis carinii pneumonia, candidiasis, cytomegalovirus, or herpes simplex.
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that T-cell lymphocytes perform is related to this type of surgery?
A cell-mediated response Explanation: A cell-mediated response occurs when T cells 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. An example of a cell-mediated response is one that occurs when an organ is transplanted. The complement system cooperates with antibodies to attract phagocytes and coat antigens to make them more recognizable for phagocytosis and stimulate inflammation and is not related to the surgery. Colony-stimulating factors prompt the bone marrow to produce, mature, and promote the functions of blood cells. Naturally acquired active immunity is a direct result of infection by a specific microorganism.
The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is:
Chronic diarrhea. Explanation: Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of AIDS can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.
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 Explanation: Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and by releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other lymphocytes and white blood cells. These cells then assist in destroying the invading organism.
A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following?
The client's immune system cannot mount a response to the skin test. Explanation: The inflammatory response is a major function of the immune system that is elicited in response to invading foreign material. A person with AIDS has a poorly functioning or non-functioning immune system that will not respond to the injected skin test. Any TB organisms should cause a reaction to the skin test in people with intact immune systems. The nurse cannot accurately speculate on how the skin test was performed or that the solution was outdated.
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.
Why would it be important for the nurse to question the client about sexual practices, history of substance use disorder, and the client's lifestyle during the interview process?
To determine if the client has practices that the client at risk for acquired immunodeficiency syndrome (AIDS) Explanation: The nurse investigates the client's allergy history and asks about practices that put the client at risk for AIDS. The interview will not determine the client's ability to be compliant. The physician would make the determination if a counseling referral should be made. It is irrelevant to determine the personality traits in the initial interview.
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 38-year-old 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. Which is the most important factor related to the client's assessment?
Use of other drugs Explanation: The nurse needs to review the client's drug history. These data will help her to assess the client's susceptibility to illness because certain past illnesses and drug use, 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 the client's susceptibility to illness.
Kaposi sarcoma (KS) is diagnosed through
biopsy. Explanation: KS is diagnosed through biopsy of the suspected lesions. Visual assessment will not confirm a diagnosis. A computed tomography scan will not assist in determining skin cell changes. Skin scraping is a procedure to collect cells, not to evaluate cells.