Chapter 35: Assessment of Immune Function QUESTIONS
A patient is admitted with cellulitis and experiences a consequent increase in white blood cell count. The nurse is aware that during the immune response, pathogens are engulfed by white blood cells that ingest foreign particles. What is this process known as?
B) Phagocytosis
A patients injury has initiated an immune response that involves inflammation. What are the first cells to arrive at a site of inflammation?
D) Neutrophils
The nurse is completing a focused assessment addressing a patients immune function. What should the nurse prioritize in the physical assessment?
D) Palpation of the patients lymph nodes
During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess?
A) Acquired immunity (Acquired immunity usually develops as a result of prior exposure to an antigen, often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three means of defense. -The first line of defense, the phagocytic immune response, involves the WBCs that have the ability to ingest foreign particles. -A second protective response is the humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells that manufacture antibodies. -The natural immune response system is rapid, nonspecific immunity present at birth.)
An infection control nurse is presenting an inservice reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining?
A) Agglutination (Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link between two antigens.)
A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of her last tetanus shot, which is over 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what?
A) Antibodies (Immunizations activate the humoral immune response, culminating in antibody production.)
A patient has undergone treatment for septic shock and received high doses of numerous antibiotics during the course of treatment. When planning the patients subsequent care, the nurse should be aware of what potential effect on the patients immune function?
A) Bone marrow suppression (Large doses of antibiotics can precipitate bone marrow suppression, affecting immune function.)
A patients exposure to which of the following microorganisms is most likely to trigger a cellular response?
A) Herpes simplex (Viral, rather than bacterial antigens, induce a cellular response.)
A patient with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the patient for which of the following complications of therapy?
A) Immunosuppression
A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact that her bone marrow is unable to produce a sufficient amount of what?
A) Lymphocytes (The white blood cells involved in immunity [including lymphocytes] are produced in the bone marrow.)
The nurse is providing care for a patient who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment?
A) Stem cell transplantation (Clinical trials using stem cells are under way in patients with a variety of disorders having an autoimmune component, including multiple sclerosis.)
A patient was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response?
B) Proliferation
A man was scratched by an old tool and developed a virulent staphylococcus infection. In the course of the mans immune response, circulating lymphocytes containing the antigenic message returned to the nearest lymph node. During what stage of the immune response did this occur?
B) Proliferation stage (The recognition stage of antigens as foreign by the immune system is the initiating event in any immune response. The body must first recognize invaders as foreign before it can react to them. In the proliferation stage, the circulating lymphocyte containing the antigenic message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. In the response stage, the differentiated lymphocytes function either in a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic [killer] T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader.)
A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this?
B) The interactions that occur between T cells and B cells (T cells interact closely with B cells, indicating that humoral and cellular immune responses are not separate, unrelated processes, but rather branches of the immune response that interact.)
The nurse is assessing a clients risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity?
B) The patient is under significant psychosocial stress
A nurse is reviewing a patients medication administration record in an effort to identify drugs that may contribute to the patients recent immunosuppression. What drug is most likely to have this effect?
C) An antineoplastic
A patient requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this patient most likely has what type of immune disorder?
C) An autoimmune disorder (Primary immune deficiency results from improper development of immune cells or tissues. These disorders are usually congenital or inherited. Autoimmune disorders are less likely to have a genetic component, though some have a genetic component. Overproduction of immunoglobulins is the hallmark of gammopathies.)
A patient with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. What is the immune response that predominates in this situation?
C) Cellular (Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. During transplantation rejection, the cellular response predominates over the humoral response.)
A patients current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by what cells?
C) Cytotoxic T cells (Cytotoxic T cells [also called CD8 + cells] participate in the destruction of foreign organisms.)
The nurse knows that the response of natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances the response of natural immunity?
C) Gastric secretions (Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi.)
A gerontologic nurse is caring for an older adult patient who has a diagnosis of pneumonia. What age-related change increases older adults susceptibility to respiratory infections?
C) Impaired ciliary action
A nurse is reviewing the immune system before planning an immunocompromised patients care. How should the nurse characterize the humoral immune response?
D) Antibodies are made by B lymphocytes in response to a specific antigen
A patient is being treated for cancer and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which of the following ways?
D) Depressing antibody response
A nursing student is giving a report on the immune system. What function of cytokines should the student describe?
D) Determining whether the immune response will be the production of antibodies or a cell-mediated response (Separate sub-populations of helper T cells produce different types of cytokines and determine whether the immune response will be the production of antibodies or a cell-mediated immune response. Cytokines do not determine whether cells are foreign, determine if lymphokines will be activated, or determine the role of memory T cells.)
A patient is being treated for bacterial pneumonia. In the first stages of illness, the patients dyspnea was accompanied by a high fever. Currently, the patient claims to be feeling better and is afebrile. The patient is most likely in which stage of the immune response?
D) Effector stage (The immune response culminates with the effector stage, during which offending microorganisms are killed by the various actions of the immune system. The patients improvement in health status is likely the result of this final stage in the immune response.)
A neonate exhibited some preliminary signs of infection, but the infants condition resolved spontaneously prior to discharge home from the hospital. This infants recovery was most likely due to what type of immunity?
D) Nonspecific immunity (Natural immunity, or nonspecific immunity, is present at birth.)
A nurse is planning a patients care and is relating it to normal immune response. During what stage of the immune response should the nurse know that antibodies or cytotoxic T cells combine and destroy the invading microbes?
D) effector stage (In the effector stage, either the antibody of the humoral response or the cytotoxic [killer] T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader. The coupling initiates a series of events that in most instances results in total destruction of the invading microbes or the complete neutralization of the toxin.)
A nurse has admitted a patient who has been diagnosed with urosepsis. What immune response predominates in sepsis?
D) humoral (Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. For example, during transplantation rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant role.)
A patient is vigilant in her efforts to take good care of herself but is frustrated by her recent history of upper respiratory infections and influenza. What aspect of the patients lifestyle may have a negative effect on immune response?
A) The patient works out at the gym twice daily. (Rigorous exercise or competitive exercise usually considered a positive lifestyle factor can be a physiologic stressor and cause negative effects on immune response.)
A nurse has administered a childs scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following?
B) Active acquired immunity (Active acquired immunity usually develops as a result of vaccination or contracting a disease.)
A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process?
B) Apoptosis
A patient is undergoing testing to determine the overall function of her immune system. What test can be performed to evaluate the functioning of the patients cellular immune system?
B) Delayed hypersensitivity skin test (Cellular [cell-mediated] immunity tests include the delayed hypersensitivity skin test, since this immune response is specifically dependent on the cellular immune response)
A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this patient knows that the site of the injury will have an invasion of what?
B) Phagocytic cells (Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken glass.)
The nurse should recognize a patients risk for impaired immune function if the patient has undergone surgical removal of which of the following?
B) spleen (A history of surgical removal of the spleen, lymph nodes, or thymus may place the patient at risk for impaired immune function.)
A nurse is caring for a patient who has had a severe antigen/antibody reaction. The nurse knows that the portion of the antigen that is involved in binding with the antibody is called what?
C) Antigenic determinant
Diagnostic testing has revealed a deficiency in the function of a patients complement system. This patient is likely to have an impaired ability to do which of the following?
C) Bridging natural and acquired immunity (Complement has 3 major physiologic functions: 1-defending the body against bacterial infection 2-bridging natural and acquired immunity 3-disposing of immune complexes and the byproducts associated with inflammation)
A patients recent diagnostic testing included a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the patients immunity?
C) Cell-mediated immune function (A total lymphocyte count is a test used to determine cellular immune function.)
A patient is responding to a microbial invasion and the patients differentiated lymphocytes have begun to function in either a humoral or a cellular capacity. During what stage of the immune response does this occur?
C) The response stage (In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. •In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader. •In the recognition stage, the recognition of antigens as foreign, or non-self, by the immune system is the initiating event in any immune response. •During the proliferation stage the circulating lymphocytes containing the antigenic message return to the nearest lymph node.)
A nurse is admitting a patient who exhibits signs and symptoms of a nutritional deficit. Inadequate intake of what nutrient increases a patients susceptibility to infection?
C) proteins (Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. As a result, the patient has an increased susceptibility to infection.)
A nurse is planning the assessment of a patient who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among what group?
c) women
