Chapter 35: Assessment of Immune Function
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?"
A parent of a child who has been having frequent bouts of tonsillitis brings the child back to the clinic for another sore throat. The parent asks the nurse, "What are tonsils good for anyway?" What is the best response by the nurse?
"These tissues filter bacteria from tissue fluid."
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
Which of the following is a medical condition that is an example of a humoral immune response?
Asthma
Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?
Ataxia
Which of the following cell types are involved in humoral immunity?
B lymphocytes
The nurse is obtaining information from a client with Crohn's disease about his medication history. 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 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 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.
An elderly client is diagnosed with cancer. While reviewing age-related changes in the immune system, what does the nurse identify as having contributed to this client's condition?
Failure of lymphocytes to recognize mutant cells
Which immunoglobulin assumes a major role in bloodborne and tissue infections?
IgG
A client is diagnosed with multiple site cancers and has received whole-body irradiation. The nurse is concerned about a compromised immune system in this client for which reason?
Radiation destroys lymphocytes.
Which condition is associated with impaired immunity relating to the aging client?
Renal function decreases
Which stage of the immune response occurs when the differentiated lymphocytes function in either a humoral or a cellular capacity?
Response stage
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
T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?
T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.
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.
The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which statement correctly describes the process of autoimmunity?
The normal protective immune response attacks the body, damaging tissues.
Which immunity type becomes active as a result of infection by a specific microorganism?
naturally acquired active immunity
A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:
neutrophils and monocytes.
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."
Which of the following is the most severe form of hypersensitivity reaction?
Anaphylaxis
Which condition is associated with impaired immunity relating to the aging client?
Breakdown and thinning of the skin
Activation of a natural immunity response is enhanced by physical and chemical barriers. Which of the following is a physical barrier, which the nurse knows can be altered by illness, nutrition, or lifestyle?
Cilia of the respiratory tract
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has 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.
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.
Cytotoxic T cell
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.
In which response do T lymphocytes have a role?
Transplant rejection
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?
Natural immunity
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
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
Lymphoid tissues, which perform a function within the immune response, are found throughout the body. While the thymus gland, tonsils and adenoids, spleen, and lymph nodes are lymphoid tissues, where else in the body can lymphoid tissues be found? Select all that apply.
intestines lungs
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
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.
The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?
Natural killer cells
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
Which type of immunity becomes active as a result of infection by a specific microorganism?
Naturally acquired active immunity
Which medication classification is known to inhibit prostaglandin synthesis or release?
Nonsteroidal anti-inflammatory drugs (in large doses)
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
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 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."
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 that his white blood cell count is low and that he 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."
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
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 school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis?
Engulfment and digestion of bacteria and foreign material
Which of the following protective responses begin with the B lymphocytes?
Humoral
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
At 39 weeks' gestation, a pregnant client visits the physician for a scheduled prenatal checkup. The physician determines that the fetus has developed an infection in utero and sends the client for an emergency cesarean delivery. The client is very concerned about the health of her unborn child. Based on knowledge of the immune system, the delivery room nurse explains about which immunoglobulin that will be increased in the fetus at the time of birth and will be actively fighting the infection?
IgG
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 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
What type of cytokine will attract neutrophils and monocytes to remove debris?
Lymphokines
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
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
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
What is the function of the thymus gland?
Programs T lymphocytes to become regulator or effector T cells
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
The nurse is beginning the physical examination of a client with a complaint of 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.
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.
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.
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.
An older adult client, who leads a sedentary lifestyle, and a younger client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. The nurse knows that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?
The older client because of age
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.
A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this client for which reason?
Use of anti-rejection drugs
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.
What types of cells are the primary targets of the healthy immune system? Select all that apply.
infectious cells foreign cells cancerous cells
Which of the following is accurate regarding acquired immunity? Select all that apply.
An immunologic response acquired during life but not present at birth Usually develops as a result of exposure to an antigen through immunization Can develop by contracting a disease
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
The nurse is caring for a patient in the hospital who is receiving a vitamin D supplement. What does the nurse understand is the importance of supplementation with this vitamin? (Select all that apply.)
Vitamin D deficiency is associated with increased risk of common cancers. Vitamin D deficiency is associated with increased risk of autoimmune disease. Vitamin D deficiency is associated with increased risk of inflammatory disorders.
Which type of cell is capable of directly killing invading organisms and producing cytokines?
Natural killer cells
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
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.
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