Immunity Practice

A 10-year-old boy has been brought to the emergency department (ED) by ambulance in apparent anaphylaxis after accidentally eating a snack bar that contained peanuts. The ED nurse should be aware that this patient's signs and symptoms are attributable to:

A massive release of histamine Anaphylaxis occurs when the body's immune system produces specific IgE antibodies toward a substance that is normally nontoxic (eg, food such as a peanut). If the substance is ingested more than once, the body releases excess amounts of the protein histamine, resulting in anaphylaxis. The pathophysiology of anaphylaxis is not a consequence of the dissolution of the basement membrane, SNS activation, or inappropriate clotting.

During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess?

Acquired immunity 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.

A nurse has given a child's scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following?

Active acquired immunity Active acquired immunity usually develops as a result of vaccination or contracting a disease. Natural immunity is present at birth and provides a nonspecific response to any foreign invader. Immunizations do not activate the process of cellular immunity. Hypersensitivity is not an expected outcome of immunization.

Which of the following is the most severe form of hypersensitivity reaction?

Anaphylaxis The most severe form of hypersensitivity reaction or immune-mediated reaction is anaphylaxis. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Type III, or immune complex, hypersensitivity involves immune complexes that are formed when antigens bind to antibodies. Type IV, or delayed-type hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.

The nurse is discussing adverse reactions involving the cardiovascular system after administration of oprelvekin. The nurse would include which reactions in the client teaching plan?

Arrhythmia Arrhythmia resulting in stroke and pulmonary edema is an expected cardiovascular system adverse reaction after the administration of oprelvekin. Drowsiness and vomiting are not expected and are not cardiac system reactions. Bone loss is skeletal and is not a known adverse reaction after the administration of oprelvekin.

A nurse is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use?

Auscultation Auscultation refers to the assessment technique of listening with a stethoscope to sounds produced in the body, such as bowel sounds. Palpation uses the sense of touch, percussion is the act of striking one object against another to produce sound, and inspection refers to observing.

Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client?

Autologous Autologous vaccines are made from the client's own cancer cells, which are obtained during diagnostic biopsy or surgery. Prophylactic vaccines, such as the polio vaccine, are given to prevent people from developing a disease. Therapeutic vaccines are given to kill existing cancer cells and to provide long-lasting immunity against further cancer development. Allogeneic vaccines are made from cancer cells that are obtained from other people who have a specific type of cancer.

The nurse is performing an assessment of a client in order to determine the functional status of the client's humoral immunity. What component of the client's immune function should the nurse prioritize?

B cells B cells provide humoral immunity. Suppressor T cells are involved with cell-mediated immunity. Natural killer cells are another type of lymphocyte that is not involved in either type of immunity. Lymphokine-activated killer cells are another type of lymphocyte that is not involved in either type of immunity.

All the following items are related to cancer. Which does not affect the immune system?

Diagnostic tests for cancer Immunosuppression contributes to the development of cancers; however, cancer itself is immunosuppressive. Diagnostic tests do not cause cancer. Radiation and chemotherapy decrease immune competency.

Surgical asepsis is defined as:

absence of all microorganisms. Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms.

Client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What action is of primary importance upon admission?

maintain airway Anaphylaxis is a rapid, profound 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. In an emergency, the primary focus of care is maintaining the airway.

The nurse working at the child community clinic must administer the influenza vaccine to the high-risk kids first. Which child would she choose?

23-month-old Ava who had heart surgery as an infant for a defect Children who are considered high risk and could benefit from the influenza vaccine are: immunocompromised; have a chronic pulmonary disease; have had a congenital abnormality, chronic renal or metabolic diseases, sickle-cell disease, HIV, and any type of neurological disorder (seizures). The other choices would be considered normal and the child is not at high risk.

The nurse is obtaining a history from a patient with severe psoriasis. What question would be the most important to ask this patient to determine a genetic predisposition?

"Does anyone in your family have more than one autoimmune disease?" The patient is asked about any autoimmune disorders, such as lupus erythematosus, rheumatoid arthritis, multiple sclerosis, or psoriasis. The onset, severity, remissions and exacerbations, functional limitations, treatments that the patient has received or is currently receiving, and effectiveness of the treatments are described. The occurrence of different autoimmune diseases within a family strongly suggests a genetic predisposition to more than one autoimmune disease (Brooks, 2010) (Chart 35-4).

Which of the following is a age-related change associated with the immune system?

Decreased antibody production 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."

The nurse is caring for an 83-year-old client admitted to the health-care facility with a new onset of confusion and a low-grade fever. Which of the following age-related changes might contribute to decreased functioning of the immune system?

Decreased kidney function Decreased kidney function, changes in lower urinary tract function (enlargement of the prostate), and altered genitourinary tract flora all contribute to increased urinary tract infections. With age, the skin thins, gastric secretions decrease, and ciliary action decreases.

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 Phagocytosis is the process of engulfing and digesting bacteria and foreign materials. It does not involve the release of chemicals or conversion of memory cells to plasma cells. The macrophages in the spleen remove bacteria and dead blood cells from circulation.

A nurse who is conducting sessions on preventing the spread of sexually transmitted infections (STIs) discovers that there is a very high incidence of hepatitis B in the community. Which measure should the nurse take to ensure the prevention of the disease?

Instruct people to get vaccinated for hepatitis B. The nurse should instruct all community members to get vaccinated for prevention of hepatitis B. Ensuring that drinking water is disease free and educating people about the risks involved with injecting drugs may help prevent hepatitis A, not hepatitis B. Delaying the start of sexual activity by teenagers may not protect them from hepatitis B in the long run.

A patient is admitted with an infected leg, and the nurse notes an increase in his white blood cell (WBC) count. The nurse is aware that, during the immune response, pathogens are engulfed by WBCs that ingest foreign particles. What is this process known as?

Phagocytosis During the first mechanism of defense, WBCs, which have the ability to ingest foreign particles, move to the point of attack, where they engulf and destroy the invading agents. This is known as phagocytosis. The action described is not apoptosis, antibody response, or a cellular immune response.

A forest ranger arrives at a community clinic for prophylactic vaccination. Which vaccine would be most important to be administered to the ranger?

Rabies vaccine The ranger has to be administered the rabies vaccine as prophylaxis as he is at high risk for contracting the virus. The MMR vaccine is used in treating measles, mumps, and rubella. The varicella vaccine is used in chickenpox, and the rotavirus vaccine is used in preventing gastroenteritis caused by the rota virus.

What organ is considered lymphoid tissue?

Spleen Lymphoid tissues, such as the thymus gland, tonsils and adenoids, spleen, and lymph nodes, play a role in the immune response and prevention of infection. The pancreas, intestines, and liver are not lymphoid tissue.

A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions?

Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens. Standard precautions are designed to reduce the risk of transmission of bloodborne pathogens and of pathogens from moist body substances. Standard precautions are used when working with all patients in all health care settings, regardless of their diagnosis or presumed infectious status (Siegel, Rhinehart, Jackson, et al., 2007).

What are the primary participants in the immune system?

T- and B- cell lymphocytes Lymphocytes, which are either T-cell or B-cell lymphocytes, comprise 20% to 30% of all leukocytes. T-cell and B-cell lymphocytes are th

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact Wound infectious agents are transmitted through contact; therefore, contact contact precautions are appropriate.

Based on the nurse's base knowledge of primary immunodeficiencies, how would the nurse complete this statement? Primary immunodeficiencies

develop early in life after protection from maternal antibodies decreases. These disorders may involve one or more components of the immune system. Primary immunodeficiencies are seen primarily in infants and young children. Primary immunodeficiencies are rare disorders with genetic origins. Without treatment, infants and children with these disorders seldom survive to adulthood.

Which statement by the parent of a 12-month-old child diagnosed with Down syndrome shows the need for further education?

"I will need to delay any further immunizations." Down syndrome children are at higher risk for infection because of a lowered immune system. Delaying immunizations may expose the child to illnesses that could have been prevented. Down syndrome children are at greater risk for developing thyroid disorders, 1st and 2nd vertebrae disorders, and respiratory infections.

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?

"I won't donate blood because I don't want to get AIDS." HIV is transmitted through infected blood, semen, and certain other body fluids. Although a transfusion with infected blood may cause HIV infection in the recipient, a person cannot become infected by donating blood. The other options reflect accurate understanding of HIV transmission.

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary." The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

The nurse is caring for a 13-year-old girl with suspected autoimmune hepatitis. The girl inquires about the testing required to evaluate the condition. How should the nurse respond?

"You will most likely have a blood test to check for certain antibodies." Anti-nuclear antibodies are one of the diagnostic tests performed to diagnose autoimmune hepatitis. Ultrasound is to assess for liver or spleen abnormalities. Viral studies are performed to screen for viral causes of hepatitis. Ammonia levels may be ordered if hepatic encephalopathy is suspected.

Which of the following patients has the highest risk of contracting an opportunistic infection?

A patient who has had HIV for 3 years and has a CD4+ count of 50 cells/μL The lower the CD4+ T-cell count is, the higher the likelihood of contracting an opportunistic infection. In a patient who is newly infected with HIV, the CD4+ T-cell count would he high, even though the viral load is high. Platelets are not an important factor when considering the opportunity for an infection.

The family of a client, stung by a bee, is rushed the client to the emergency room. The client is experiencing hives and redness at the site. Upon arrival, the client states, "I feel a lump in my throat and I am sweating. I can't breathe! I think I am going to die!" The nurse anticipates which emergency treatment next?

Administer an injection of epinephrine stat. Symptoms of hives and redness at the bee sting site coupled with a progression of symptoms including respiratory difficulty and an impending feeling of doom indicate anaphylaxis. Emergency treatment of anaphylaxis is an injection of epinephrine. Bronchodilators may help but are not the primary treatment. β-adrenergic blockers are not indicated in the management of anaphylaxis because they may cause bronchospasm. Having the client in high Fowler's position is appropriate but not emergency treatment.

Some members of the population are so sensitive to certain antigens that they react within minutes by developing itching, hives, and skin erythema, followed shortly thereafter by bronchospasm and respiratory distress. What is this near immediate reaction commonly known as?

Anaphylactic reaction Anaphylaxis is a systemic life-threatening hypersensitivity reaction characterized by widespread edema, vascular shock secondary to vasodilation, and difficulty breathing. It is not called an antigen reaction, neither is it called an Arthus reaction.

The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?

Apply an allergy bracelet and flag the chart. The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.

Incidence of fungal infections has increased with the rising number of people who are immunocompromised. What groups are considered to have a compromised immune system? (Select all that apply.)

Clients with acquired immune deficiency syndrome (AIDS) and AIDS-related complex (ARC) Clients taking immunosuppressant drugs Clients who have undergone transplantation surgery or cancer treatment The elderly The incidence of fungal infections has increased with the rising number of people who are immunocompromised. This group includes clients with acquired immune deficiency syndrome (AIDS) and AIDS-related complex (ARC), those taking immunosuppressant drugs, those who have undergone transplantation surgery or cancer treatment, and members of the increasingly large elderly population, whose bodies are no longer able to protect against the many fungi found throughout the environment.

A female client is prescribed a first-generation antihistamine for her allergies. The nurse would expect her to experience what adverse effect?

Dry mouth First-generation antihistamines have substantial anticholinergic effects; therefore, they may cause dry mouth, urinary retention, constipation, and blurred vision.

When providing client teaching to parents regarding measles, mumps, and rubella vaccine administration, which is most important regarding the schedule for administration?

It is administered at 12 to 15 months. Measles, mumps, and rubella immunization is administered initially at 12 to 15 months of age. The vaccine is not administered under the age of 1 year.

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

Keeping sterile field above waist level When setting up a sterile field, the correct technique is to keep the sterile field above the waist level. A nurse would open the sterile package away from him- or herself first. The sterile gloves are applied after the sterile container is opened. The sterile field is maintained with a 1-in (2.5-cm) border.

When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?

Risk for infection related to altered immune cell function Although anxiety and impaired skin integrity may be appropriate, the priority nursing diagnosis for any immunodeficiency is the risk for infection. Although primary immunodeficiencies can be serious, they are rarely fatal. Therefore, the nursing diagnosis of grieving would be inappropriate.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?

Surgical asepsis Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter. Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.

Why would it be important for the nurse to question the client about sexual practices, history of substance abuse, and his lifestyle during the interview process?

To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS) The nurse investigates the client's allergy history and questions the client about practices that put him or her 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.

A nurse has been administering seasonal influenza vaccinations to the residents of a long-term care facility. One resident has refused the vaccinations, stating that he believes the vaccination to be a cause of influenza infection rather than a protection against it. The nurse's response to this resident should encompass which of the following facts about vaccination?

Vaccination prompts the body to produce antibodies against influenza. Exposure to attenuated virus, such as the influenza vaccine, prompts the production of antibodies against influenza. Immunity may be long-lasting, but is often not life-long. Re-exposure to influenza initiates a cascade of immune responses that are more rapid and capable of controlling the virus. Patients either eliminate the virus from their system or have a milder case of influenza. The vaccine prompts an immune response; it is not cytotoxic to the microorganism in question.

During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?

a bouquet of flowers The induction phase of chemotherapy is an aggressive treatment to kill leukemia cells. The client is severely immunocompromised and severely at risk for infection. Flowers, herbs, and plants should be avoided during this time. The client's prayer book, pictures, and other personal belongings can be cleaned before being brought into the room to prevent client contact with pathogenic and nonpathogenic organisms.

The nurse is admitting four clients with infections to the medical-surgical unit, but only one negative pressure room is available. Which client is it most appropriate to assign to the negative pressure room?

a client with a cough who may have tuberculosis (TB) The client with suspected TB needs to have airborne precautions and a negative pressure room. Clients with C. difficile and VRE require contact precautions and should ideally be placed in private rooms, but could be placed in rooms with other clients with the same diagnosis. Standard precautions are required for the client with TSS.

During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses:

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.

A client with burns has developed a wound infection. This client is experiencing what type of wound infection?

opportunistic infection Opportunistic infections are likely to occur in people with severe burns, cancer, human immunodeficiency virus, and indwelling catheters and are often caused by drug-resistant microorganisms, are usually serious, and may be life threatening. The client may be at risk for a fungal, nosocomial, or food-borne infection, but the risk for all infections is high due to the client's opportunistic nature of the burn.

A 24-year-old client presents in labor. The nurse notes there is an order to administer RhoGAM after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?

prevent maternal D antibody formation. Because RhoGAM contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of RhoGAM does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation

A client with rheumatoid arthritis is taking high doses of nonsteroidal anti-inflammatory medications. The nurse should instruct the client to:

take prescribed medication with food to lessen the likelihood of an upset stomach. Gastric upset is a side effect of nonsteroidal anti-inflammatory medications; taking medication with food minimizes this effect. Corticosteroids affect adrenal gland function and are discontinued by lowering the dose gradually, but this is not true of nonsteroidal anti-inflammatory medications. It is not necessary to rinse the mouth, as stomatitis is not a usual side effect. Dizziness is not an effect of this drug.

A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the priority nursing action the nurse must perform before leaving the client's room?

thorough handwashing Since the client has an infectious disease, the most important nursing action is to perform thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care item. Spraying a disinfectant before leaving the client's room, or placing one bag of contaminated items in another is not the most important nursing action in this case. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. Nurses remove the personal protective equipment that is most contaminated first to preserve the clean uniform underneath.