Immunology and Infection

1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic infusion. b. Give diphenhydramine (Benadryl) IV. c. Inject epinephrine (Adrenalin) IM or IV. d. Prepare an infusion of dopamine (Intropin). e. Start 100% oxygen using a nonrebreather mask.

ANS: A, E, C, B, D The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last.

8. In each of the following situations identify which option has the highest risk for human immunodeficiency virus (HIV) transmission? a. Transmission to women or to men during heterosexual intercourse b. Hollow-bore needle used for vascular access or used for IM injection c. First 2 to 4 weeks of infection or 1 year after infection d. Perinatal transmission from HIV-infected mothers taking antiretroviral therapy (ART) or HIV-infected mothers using no therapy e. A splash exposure of HIV-infected blood on skin with an open lesion or a needle-stick exposure to HIV-infected blood

a. women; b. vascular access; c. first 2 to 4 weeks of infection; d. HIV- infected mothers using no therapy; e. needle-stick exposure to HIV- infected blood

26. Which characteristics are seen with acute transplant rejection (select all that apply)? a. Treatment is supportive b. Only occurs with transplanted kidneys c. Organ must be removed when it occurs d. The recipient's T cytotoxic lymphocytes attack the foreign organ e. Long-term use of immunosuppressants necessary to combat the rejection f. Usually reversible with additional or increased immunosuppressant therapy

d, e, f. Acute transplant rejection occurs when the recipient's T cytotoxic lymphocytes attack the foreign organ. Long-term immunosuppressants help combat it, and it is usually reversible with additional immunosuppression. Treatment of chronic rejection is supportive and irreversible with infiltration of the organ with B and T lymphocytes. Hyperacute rejection occurs when the recipient has antibodies against the donor's human leukocyte antigen (HLA), is most common with kidney transplants, and results in the organ having to be removed.

3. What are the recommended measures to prevent the transmission of health care- associated infections (HAIs) (select all that apply)? a. Empty bedpans as soon as possible. b. Limit fresh flowers in patient rooms. c. Remove urinals from bedside tables. d. Use of personal protective equipment. e. Wash hands or use alcohol-based sanitizer. f. Make sure patients wear sandals in the shower.

d, e. T he occupational Safety and Health Administration (OSHA) requires hand washing and the use of alcohol-based sanitizers and personal protective equipment (e.g., gloves) to prevent health care- associated infections (HAIs). Although the other interventions will not hurt a patient and they are good practice, they will not prevent HAIs.

9. Place the following events of HIV infection of a cell in sequence from 1 (first) to 7 (last). _______ a. The release of reverse transcriptase converts HIV ribonucleic acid (RNA) into a single strand of DNA. _______ b. Viral DNA is spliced into cell genome using the enzyme integrase. _______ c. HIV binds with CD4+ T cell protein receptors on the outside of the cell (fusion). _______ d. Viral DNA directs the cell to replicate infected daughter cells and makes more HIV. _______ e. Viral RNA enters the host CD4+ T cell. _______ f. Long strands of viral RNA are cut in the presence of protease and released before CD4+ T cell destruction. _______ g. Single-stranded viral DNA replicates into double-stranded DNA.

9. a. 3; b. 5; c. 1; d. 6; e. 2; f. 7; g. 4

17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matching

ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing.

1. A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient? a. The EIA test will need to be repeated to verify the results. b. A viral culture will be done to determine the progression of the disease. c. It will probably be 10 or more years before you develop acquired immunodeficiency syndrome (AIDS). d. The Western blot test will be done to determine whether acquired immunodeficiency syndrome (AIDS) has developed.

ANS: A After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not usually part of HIV testing. It is not appropriate for the nurse to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.

15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. After a couple of years, it is likely that I will be able to stop taking the cyclosporine. b. If I develop an acute rejection episode, I will need to have other types of drugs given IV. c. I need to be monitored closely because I have a greater chance of developing malignant tumors. d. The drugs are given in combination because they inhibit different ways the kidney can be rejected.

ANS: A Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

6. Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patients human immunodeficiency virus (HIV) status is unknown? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with patient vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure

ANS: A Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patients blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

3. A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils

ANS: A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

11. Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation

ANS: A The current Center for Disease Control (CDC) policy is to offer routine testing for HIV to all individuals age 13 to 64. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.

17. To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay

ANS: A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

19. A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? a. Administer epinephrine. b. Apply topical hydrocortisone. c. Monitor the patient for lower extremity edema. d. Ask the patient about exposure to any new lotions or soaps.

ANS: A The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction. Exposure to lotions and soaps does not address the immediate concern of a possible anaphylactic reaction. The nurse should not wait and observe for edema. The nurse should act immediately in order to prevent progression to anaphylaxis.

21. An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching? a. Many medications have interactions with antiretroviral drugs. b. Less frequent CD4+ level monitoring is needed in older adults. c. Hospice care is available for patients with terminal HIV infection. d. Progression of HIV infection occurs more rapidly in older patients

ANS: A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient with asymptomatic HIV infection is not a candidate for hospice. Progression of HIV is not affected by age, although it may be affected by chronic disease.

13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patients skin rash? a. The donor T cells are attacking the patients skin cells. b. The patients antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection.

ANS: A The patients history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patients tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.

4. An older adult patient who is having an annual check-up tells the nurse, I feel fine, and I dont want to pay for all these unnecessary cancer screening tests! Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-stimulating infections in older individuals

ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

1. The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. V aricella zoster immune globulin

ANS: A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.

3. The nurse plans a presentation for community members about how to decrease the risk for antibiotic- resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Continue taking antibiotics until all the medication is gone. b. Antibiotics may sometimes be prescribed to prevent infection. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

ANS: A, B, E All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a future infection. Hand washing is generally considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza.

22. The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient about how to use tissues to dispose of respiratory secretions. b. Stock the patients room with all the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patients family members the reason for the use of airborne precautions.

ANS: B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.

1. The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

16. The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time? a. Oral acyclovir (Zovirax) b. Oral saquinavir (Invirase) c. Nystatin (Mycostatin) tablet d. Aerosolized pentamidine (NebuPent)

ANS: B It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

5. A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, I am very nervous about making my baby sick. Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 119 b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART).

ANS: B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

12. A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. Avoid sexual intercourse when using injectable drugs. b. It is important to participate in a needle-exchange program. c. You should ask those who share equipment to be tested for HIV. d. I recommend cleaning drug injection equipment before each use.

ANS: B Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

9. The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan? a. Plasmapheresis will eliminate eosinophils and basophils from blood. b. Plasmapheresis will remove antibody-antigen complexes from circulation. c. Plasmapheresis will prevent foreign antibodies from damaging various body tissues. d. Plasmapheresis will decrease the damage to organs caused by attacking T lymphocytes.

ANS: B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

19. Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/L and an undetectable viral load. What is the priority nursing intervention at this time? a. Teach about the effects of antiretroviral agents. b. Encourage adequate nutrition, exercise, and sleep. c. Discuss likelihood of increased opportunistic infections. d. Monitor for symptoms of acquired immunodeficiency syndrome (AIDS).

ANS: B The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection, when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

20. A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurses priority action? a. Have the patient lie down. b. Assess the patients airway. c. Administer high-flow oxygen. d. Remove the stinger from the site.

ANS: B The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance.

14. An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

2. According to the Center for Disease Control (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium difficile(select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

ANS: B, C Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.

15. A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

ANS: C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

3. A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient about the medications available for treatment. b. Inform the patient how to protect sexual and needle-sharing partners. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to notify individuals who have had risky contact with the patient.

ANS: C After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.

6. Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies? A. Do not eat anything for about 6 hours before the testing. B. Take an oral antihistamine about an hour before the testing. C. Plan to wait in the clinic for 20 to 30 minutes after the testing. D. Reaction to the testing will take about 48 to 72 hours to occur.

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

23. The health care provider asks the nurse whether a patients angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Ask the patient about any clear nasal discharge. b. Obtain the patients blood pressure and heart rate. c. Check for swelling of the patients lips and tongue. d. Assess the patients extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. I need to find another way to earn extra money. b. I will get a prescription for epinephrine and learn to self-inject it. c. I will plan to take oral antihistamines daily before going to work. d. I should wear a Medic-Alert bracelet indicating my allergy to bee stings.

ANS: C Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patients hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.

7. The nurse, who is reviewing a clinic patients medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate? a. Schedule an additional dose that week. b. Administer the usual dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patients sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

2. A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by passive immunity. Which example should the nurse use to explain this type of immunity? Early immunization Bone marrow donation Breastfeeding her infant Exposure to communicable diseases

ANS: C Colostrum provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. It requires that the infant has an immune response after exposure to an antigen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active immunity.

2. A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. The patient meets the criteria for a diagnosis of an acute HIV infection. b. The patient will be diagnosed with asymptomatic chronic HIV infection. c. The patient has developed acquired immunodeficiency syndrome (AIDS). d. The patient will develop symptomatic chronic HIV infection in less than a year.

ANS: C Development of PCP meets the diagnostic criterion for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.

7. A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Driving is allowed when starting this medication. b. Report any bizarre dreams to the health care provider. c. Continue to use contraception while on this medication. d. Take this medication in the morning on an empty stomach.

ANS: C Efavirenz can cause fetal anomalies and should not be used in patients who may be pregnant. The drug should not be used during pregnancy because large doses could cause fetal anomalies. Once-a-day doses should be taken at bedtime (at least initially) to help patients cope with the side effects that include dizziness and confusion. Patients should be cautioned about driving when starting this drug. Patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams.

10. The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Advise the patient that this is probably the flu. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.

ANS: C Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Applying ice to the neck may provide comfort, but the initial action is to reassure the patient this is an expected finding. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu.

24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is low

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable.

23. The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

ANS: C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

12. Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness

ANS: C Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.

11. Which statement by a patient would alert the nurse to a possible immunodeficiency disorder? a. I take one baby aspirin every day to prevent stroke. b. I usually eat eggs or meat for at least 2 meals a day. c. I had my spleen removed many years ago after a car accident. d. I had a chest x-ray 6 months ago when I had walking pneumonia.

ANS: C Splenectomy increases the risk for septicemia from bacterial infections. The patients protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function.

20. Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose latest CD4+ count is 250/L b. Patient whose rapid HIV-antibody test is positive c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs

ANS: C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.

8. While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate? a. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. Document the patients allergy history and be alert for any clinical manifestations of a type I latex allergy. d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.

ANS: C The patients allergy history and occupation indicate a risk of developing a latex allergy. The nurse should be prepared to manage any symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely.

18. The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient who had an anaphylactic reaction.

21. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first? a. Remind the patient to remain calm. b. Administer subcutaneous epinephrine. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site.

ANS: C application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. Aantiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action.

25. A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patients IgG level is increased. b. The injection site is red and swollen. c. The patients allergy symptoms have not improved. d. There is a 2-cm wheal at the site of the allergen injection.

ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patients symptoms is not expected after a few months.

18. The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patients blood glucose level is 142 mg/dL. b. The patient complains of feeling constantly tired. c. The patient is unable to state the side effects of the medications. d. The patient states, Sometimes I miss a dose of zidovudine (AZT).

ANS: D Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common side effects of ART. The nurse should discuss medication side effects with the patient, but this is not as important as addressing the skipped doses of AZT.

9. The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/L c. HIV-positive patient with CD4+ count of 160/L who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retiniti

ANS: D CMV retinitis is an acquired immunodeficiency syndrome (AIDS)-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.

8. A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/L. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. HIV genotype and phenotype b. Patients social support system c. Potential medication side effects d. Patients ability to comply with ART schedule

ANS: D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.

16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patients health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

ANS: D Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patients many concerns should be addressed, but these are not potentially life-threatening problems.

22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.

ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching.

4. A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, I feel obsessed with thoughts about dying. Do you think I am just being morbid? Which response by the nurse is best? a. Thinking about dying will not improve the course of AIDS. b. It is important to focus on the good things about your life now. c. Do you think that taking an antidepressant might be helpful to you? d. Can you tell me more about the kind of thoughts that you are having?

ANS: D More assessment of the patients psychosocial status is needed before taking any other action. The statements, Thinking about dying will not improve the course of AIDS and It is important to focus on the good things in life discourage the patient from sharing any further information with the nurse and decrease the nurses ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patients feelings

10. The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation? a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Numbness and tingling

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

13. Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patients class schedule to help decide when the drugs should be taken.

ANS: D The best approach to improve adherence is to learn about important activities in the patients life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the patients schedule.

14. A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.

ANS: D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection.

2. Name 3 of the antibiotic-resistant bacteria that are of current concern in North America: ____________________, ____________________, and ____________________.

Currently, the antibiotic-resistant bacteria are methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant enterococci (VRE); vancomycin-resistant S. aureus (VRSA); carbapenem-resistant Enterobacteriaceae (CRE); and penicillin-resistant Streptococcus pneumoniae (PRSP).

7. The nurse realizes that the patient understands the teaching about decreasing the risk for antibiotic-resistant infection when the patient makes which statement? a. "I know I should take the antibiotic for 1 day after I feel better." b. "I want an antibiotic ordered for my cold so that I can feel better sooner." c. "I always save some pills because I get the illness again after I first feel better." d. "I will follow the directions for taking the antibiotic so that I will get over this infection."

D. One of the most important factors in the development of antibiotic- resistant strains of organisms has been inappropriate use of antibiotics. Following directions regarding timing and completion of antibiotics will prevent antibiotic-resistant bacteria from developing. Antibiotics are not effective against viruses that cause colds and flu. Not completing the antibiotic regimen may allow the hardiest bacteria to survive and multiply and the potential development of an antibiotic-resistant infection.

14. What are examples of type I or IgE-mediated hypersensitivity reactions (select all that apply)? a. Asthma b. Urticaria c. Angioedema d. Allergic rhinitis e. Atopic dermatitis f. Contact dermatitis g. Anaphylactic shock h. Transfusion reactions i. Goodpasture syndrome

a, b, c, d, e, g. These are the atopic or anaphylactic responses that can be seen with a type I or IgE-mediated hypersensitivity reaction to specific allergens. Contact dermatitis is seen with a type IV or delayed hypersensitivity reaction. Transfusion reactions and Goodpasture syndrome are seen with a type II or cytotoxic hypersensitivity reaction.

1. To what is the increase in emerging and untreatable infections attributed (select all that apply)? a. Global travel and bioterrorism b. The evolution of infectious agents c. Use of antibiotics to treat viral infections d. Transmission of infectious agents from humans to animals e. An increased number of immunosuppressed and chronically ill people

a, b, c, e. Global travel and bioterrorism have increased the spread of infectious agents. Infectious agents, such as the human immunodeficiency virus (HIV) and hantavirus, have evolved to affect humans through closer association with animals as human populations push into wild animal habitats. The transfer of infectious agents from animals to humans has also resulted in West Nile virus and avian flu. Bacterial infections have also become untreatable as the result of genetic and biochemical changes stimulated by unnecessary or inadequate exposure to antibiotics. The increased number of immunosuppressed and chronically ill people also increase the emergence of untreatable infections. Transmission of infectious agents from humans to animals does not increase this number.

10. Which characteristic describes IgE (select all that apply)? a. Assists in parasitic infections b. Responsible for allergic reactions c. Present on the lymphocyte surface d. Assists in B-lymphocyte differentiation e. Predominant in secondary immune response f. Protects body surfaces and mucous membranes

a, b. Immunoglobulin E (IgE) causes allergic reactions and assists in parasitic infections. IgD assists in B-lymphocyte differentiation and is present on the lymphocyte surface. IgG is predominant in the secondary immune response. IgA protects body surfaces and mucous membranes.

11. What are the important functions of cell-mediated immunity (select all that apply)? a. Fungal infections b. Transfusion reactions c. Rejection of transplanted tissues d. Contact hypersensitivity reactions e. Immunity against pathogens that survive inside cells

a, c, d, e. Functions of cell-mediated immunity include fungal infections, rejection of foreign tissue, contact hypersensitivity reactions, immunity against pathogens that survive inside cells, and destruction of cancer cells and tuberculosis. Transfusion reactions are from humoral immunity.

2. What accurately describes artificial passive acquired immunity (select all that apply)? a. Gamma globulin injection b. Immunization with antigen c. Immediate effect, lasting a short time d. Maternal immunoglobulins in neonate e. Boosters may be needed for extended protection

a, c. Artificial passive acquired immunity is received from the injection of gamma globulin, provides immediate immunity, and may last for several weeks or months. Immunization with an antigen and the need for boosters contribute to artificial active acquired immunity. Maternal immunoglobulins in the neonate provide temporary natural passive acquired immunity.

9. Which immunoglobulins will initially protect a newborn baby of a breastfeeding mother (select all that apply)? a. IgA b. IgD c. IgE d. IgG e. IgM

a, d. IgA is passed to the neonate in the colostrum and breast milk; and IgG crosses the placenta for fetal protection.

17. A patient was given an IM injection of penicillin in the gluteus maximus and developed dyspnea and weakness within minutes following the injection. Which additional assessment findings indicate that the patient is having an anaphylactic reaction (select all that apply)? a. Wheezing b. Hypertension c. Rash on arms d. Constricted pupils e. Slowed strong pulse f. Feeling of impending doom

a, f. Wheezing and a feeling of impending doom can both occur with anaphylaxis. Other common physiologic systemic anaphylactic responses are hypotension; dilated pupils; rapid, weak pulse; and edema and itching at the injection site. An arm rash would be more likely with a simple allergic reaction.

11. What is a primary reason that the normal immune response does not contain HIV infection? a. CD4+ T cells become infected with HIV and are destroyed. b. The virus inactivates B cells, preventing the production of HIV antibodies. c. Natural killer cells are destroyed by the virus before the immune system can be activated. d. Monocytes ingest infected cells, differentiate into macrophages, and shed viruses in body tissues.

a. Activated CD4+ T cells are the target cells for HIV virus and are destroyed after replication of HIV. CD4+ T cells normally are a major component of the immune system and when infected and destroyed, the immune system is ineffective against HIV and other agents. The virus does not affect natural killer cells, and B lymphocytes are functional early in the disease, as evidenced by positive antibody titers against HIV. Monocytes and tissue macrophages ingest infected cells and may become sites of HIV replication and spread the virus, but this does not make the immune response ineffective.

25. Priority Decision: A patient with advanced AIDS has a nursing diagnosis of confusion because of neurologic changes. In planning care for the patient, what should the nurse set as the highest priority? a. Maintain a safe patient environment b. Provide a quiet, nonstressful environment to avoid overstimulation c. Use memory cues, such as calendars and clocks, to promote orientation d. Provide written instructions of directions to promote understanding and orientation

a. All the nursing interventions are appropriate for a patient with confusion, but the priority is the safety of the patient when cognitive and behavioral problems impair the ability to maintain a safe environment.

16. Which opportunistic disease associated with AIDS is characterized by vascular lesions of the skin, mucous membranes, and viscera? a. Kaposi sarcoma b. Candida albicans c. Herpes simplex type 1 infection d. Varicella-zoster virus infection

a. Vascular lesions of skin, mucous membranes, and viscera are seen in Kaposi sarcoma. Candida albicans is a common yeast infection of the mouth, esophagus, gastrointestinal (GI) tract, or vagina. Herpes simplex type 1 infection has oral and mucocutaneous vesicular and ulcerative lesions. Varicella-zoster virus infection or shingles is a maculopapular, pruritic rash along dermatomal planes.

18. Priority Decision: The patient is admitted from a nearby park with an apparent anaphylactic reaction to a bee sting. He is experiencing dyspnea and hypotension with swelling at the site. Number the following in the order of priority that the nurse should implement the actions for this patient. a. _______ Remove the stinger b. _______ Ensure a patent airway c. _______ Prepare to administer epinephrine d. _______ Start IV for fluid and medication access e. _______ Anticipate intubation with severe respiratory distress f. _______ Have diphenhydramine (Benadryl) and nebulized albuterol available

a. 3; b. 1; c. 5; d. 4; e. 2; f. 6. Airway is always first. Anticipation of intubation with severe respiratory distress is needed. Knowing that the patient has a bee sting, the stinger will be removed if present. Then an IV is started and preparation to administer epinephrine is done. Having diphenhydramine and nebulized albuterol as well as methylprednisolone IV available is important, as they may be needed. Oxygen will be used for dyspnea. For hypotension, the patient will be placed recumbent with elevated legs, and IV saline will be used.

15. Which characteristics describe Pneumocystis jiroveci infection, an opportunistic disease that can be associated with HIV? a. May cause fungal meningitis b. Diagnosed by lymph node biopsy c. Pneumonia with dry, nonproductive cough d. Viral retinitis, stomatitis, esophagitis, gastritis, or colitis

a. Vascular lesions of skin, mucous membranes, and viscera are seen in Kaposi sarcoma. Candida albicans is a common yeast infection of the mouth, esophagus, gastrointestinal (GI) tract, or vagina. Herpes simplex type 1 infection has oral and mucocutaneous vesicular and ulcerative lesions. Varicella-zoster virus infection or shingles is a maculopapular, pruritic rash along dermatomal planes.

5. A 78-year-old patient has developed an infection caused by Haemophilus influenzae. In addition to standard precautions, what should the nurse use to protect herself when working within 3 feet of the patient? a. Mask b. Gown c. Shoe covers d. Particulate respirator

a. With influenza, a surgical mask will be worn when the nurse is 3 feet or closer to the patient to avoid droplet transmission. The gown and gloves will be used as with standard precautions when working closely with the patient and there is a risk of contamination. Shoe covers are used in surgery. Particulate respirators are used for airborne precautions (e.g., tuberculosis [TB]).

17. A patient comes to the clinic and requests testing for HIV infection. Before administering testing, what is most important for the nurse to do? a. Ask the patient to identify all sexual partners. b. Determine when the patient thinks exposure to HIV occurred. c. Explain that all test results must be repeated at least twice to be valid. d. Discuss prevention practices to prevent transmission of the HIV to others.

b. Because there is a median delay of several weeks after infection before antibodies can be detected, testing during this "window" may result in false-negative results. Risky behaviors that may expose a person to HIV should be discussed and possible scheduling for repeat testing done. Positive results on initial testing will be verified by additional testing. Identification of sexual partners and prevention practices are important but do not relate immediately to the testing situation.

22. Although the cause of autoimmune disorders is unknown, which factors are believed to be present in most conditions (select all that apply)? a. Younger age b. Male gender c. Inheritance of susceptibility genes d. Initiation of autoreactivity by triggers e. Frequent viruses throughout the lifetime

c, d. Autoimmune causative factors are genetic susceptibility and initiation of autoreactivity by a trigger that may include specific viruses or medications. Females and older patients are more likely to develop autoimmune diseases

21. A 32-year-old male veteran tells the nurse he gets a headache, sore throat, shortness of breath, and nausea when his girlfriend wears perfume and when he was painting her apartment. He is afraid he has cancer. What does the nurse suspect may be the patient's problem? a. He has posttraumatic stress disorder. b. He has multiple chemical sensitivities. c. He needs to wear a mask when he paints. d. He is looking for an excuse to break up with his girlfriend.

b. Multiple chemical sensitivities are commonly seen with scented products, paint fumes, petroleum products, smoke, pesticides, plastics, and synthetic products. Symptoms vary but include headache, sore throat, breathing problems, nausea, fatigue, congestion, dizziness, muscle pain, skin rash, gastrointestinal (GI) problems, confusion, difficulty concentrating, memory problems, and mood changes. His symptoms do not indicate posttraumatic stress disorder. A mask may help when he paints, but it would be better to avoid painting. Psychotherapy is currently recommended.

7. Where and into what do activated B lymphocytes differentiate? a. Spleen; natural killer cells that destroy infected cells b. Bone marrow; plasma cells that secrete immunoglobulins c. Thymus; memory B cells that retain a memory of the antigen d. Bursa of Fabricius; helper cells that in turn activate additional B lymphocytes

b. B lymphocytes activated in the bone marrow by the presentation of an antigen differentiate into many plasma cells that secrete immunoglobulins and only a few memory cells that retain recognition of the antigen as foreign. Helper cells are T lymphocytes and natural killer cells are large, granular lymphocytes that are neither B nor T lymphocytes. The spleen filters foreign substances from the blood. T lymphocytes differentiate in the thymus. The bursa of Fabricius is found in birds, not humans.

6. What is included in the humoral immune response? a. Surveillance for malignant cell changes b. Production of antigen-specific immunoglobulins c. Direct attack of antigens by activated B lymphocytes d. Releasing cytokines responsible for destruction of antigens

b. B lymphocytes differentiating into plasma cells and producing immunoglobulins (or antibodies) is the essential component in humoral immunity. Tumor surveillance and the production of cytokines are functions of T lymphocytes in cellular immunity. B lymphocytes do not directly attack antigens.

3. How does an antigen stimulate an immune response? a. It circulates in the blood, where it comes in contact with circulating macrophages. b. It is captured and processed by a macrophage and then presented to lymphocytes. c. It is a foreign protein that has antigenic determinants different from those of the body. d. It combines with larger molecules that are capable of stimulating production of antibodies.

b. Both B and T lymphocytes must be sensitized by a processed antigen to activate the immune response. Processing involves the taking up of an antigen by macrophages, expression of the antigen on the macrophage cell membrane, and presentation to the lymphocytes. Antigens do not need to be proteins, and a few antigens may combine with larger molecules that are antigenic.

27. The patient is experiencing fibrosis and glomerulopathy a year after a kidney transplant. Which type of rejection is occurring? a. Acute b. Chronic c. Delayed d. Hyperacute

b. Chronic rejection of a kidney transplant manifests as fibrosis and glomerulopathy (seen with proteinuria, edema, and renal failure), occurs over months or years, and is irreversible. Acute rejection occurs in the first 6 months after transplant. Delayed rejection is not a term used with transplantation. Hyperacute rejection occurs minutes to hours after transplantation and is rare.

4. A patient with diarrhea has been diagnosed with Clostridium difficile. Along with standard precautions, which kind of transmission-based precautions will be used when the nurse is caring for this patient? a. Droplet precautions b. Contact precautions c. Isolation precautions d. Airborne precautions

b. Contact precautions are used with standard precautions when microorganisms can be transmitted by direct patient contact. Droplet precautions are used to minimize contact with pathogens that are spread through the air at close contact and that affect the respiratory system. Isolation precautions is a general term. Airborne precautions are used if the organism can cause infection over long distances when suspended in the air.

6. An 82-year-old male patient with cardiac disease who is in the intensive care unit (ICU) is beginning to have decreased cognitive function. What should the nurse first suspect as a potential cause of this change? a. Fatigue b. Infection c. ICU psychosis d. Medication allergy

b. Infection in older adults often has atypical presentations, with cognitive and behavioral changes occurring before fever, pain, or altered laboratory values. Fatigue and ICU psychosis could be occurring, but these are not as dangerous for the patient as infection can be. Cognitive and behavioral changes are not typical manifestations of medication allergy.

1. Which type of immunity is the result of contact with the antigen through infection and is the longest lasting type of immunity? a. Innate immunity b. Natural active acquired immunity c. Artificial active acquired immunity d. Artificial passive acquired immunity

b. Natural active acquired immunity is a result of exposure to the antigen via infection and the longest lasting type of immunity. Innate immunity is present at birth and its primary role is first-line defense against any pathogens. Artificial active acquired immunity is from immunization and also lasts a long time. Artificial passive acquired immunity is from gamma globulin injection and is immediate but short lived.

21. After teaching a patient with HIV infection about using antiretroviral drugs, the nurse recognizes that further teaching is needed when the patient says a. "I should never skip doses of my medication, even if I develop side effects." b. "By taking my HIV medications I will be able to lower by CD4 + cell count." c. "I should not use any over-the-counter drugs without checking with my health care provider (HCP)." d. "If I develop a headache with nausea and vomiting, I should report it to my HCP."

b. The goal of antiretroviral therapy is to decrease the HIV viral load. In addition, the goal is to keep the CD4 + cell count from declining. The other options show understanding.

genes to evaluate resistance to antiretroviral drugs. 19. Treatment with 2 nucleoside reverse transcriptase inhibitors (NRTIs) and an integrase inhibitor is prescribed for a patient with HIV infection. The patient asks why so many drugs are necessary for treatment. What should the nurse explain is the primary reason for combination therapy? a. Cross-resistance between specific antiretroviral drugs is reduced when drugs are given in combination. b. Combinations of antiretroviral drugs decrease the potential for developing antiretroviral-resistant HIV variants. c. Side effects of the drugs are reduced when smaller doses of 3 different drugs are used rather than large doses of 1 drug. d. When CD4+ T-cell counts are < 500/μL, a combination of drugs that have different actions is more effective in slowing HIV growth.

b. The major advantage of combination antiretroviral therapy (ART) is the inhibition of viral replication in several ways as well as decreasing the likelihood of drug resistance, the major factor that limits the ability of ART drugs to inhibit virus replication when they are used alone. The drugs selected should be ones with which the patient has not been previously treated and that are not cross-resistant with antiretroviral agents previously used by the patient.

23. Why is plasmapheresis indicated in the treatment of autoimmune disorders? a. To obtain plasma for analysis and evaluation of specific autoantibodies b. To decrease high lymphocyte levels in the blood to prevent immune responses c. To remove autoantibodies, antigen-antibody complexes, and inflammatory mediators of immune reactions d. To add monocytes to the blood to promote removal of immune complexes by the mononuclear phagocyte system

c. Plasmapheresis is the removal of plasma from the blood and in autoimmune disorders is used to remove pathogenic substances found in plasma, such as autoantibodies, antigen-antibody complexes, and inflammatory mediators. Circulating blood cells are not affected by plasmapheresis, nor are blood cells added.

15. Which type of hypersensitivity reaction occurs with rheumatoid arthritis and acute glomerulonephritis? a. Type I or IgE-mediated hypersensitivity reaction b. Type II or cytotoxic hypersensitivity reaction c. Type III or immune-complex-mediated hypersensitivity reaction d. Type IV or delayed hypersensitivity reaction

c. With rheumatoid arthritis and acute glomerulonephritis, type III or immune-complex reaction is seen when the antigens combined with IgG and IgM are too small to be removed by the mononuclear phagocytic system and are deposited in tissue, which activates the complement system and lead to inflammation and destruction of the involved tissue.

19. Which rationale describes treatment of atopic allergies with immunotherapy? a. It decreases the levels of allergen-specific T helper cells. b. It decreases the level of IgE so that it does not react as readily with an allergen. c. It stimulates increased IgG to bind with allergen-reactive sites, preventing mast cell-bound IgE reactions. d. It gradually increases the amount of allergen in the body until it is no longer recognized as foreign and does not elicit an antibody reaction

c. Allergic individuals have elevated levels of IgE, which react with allergens to produce symptoms. Immunotherapy involves injecting allergen extracts that will stimulate increased IgG, which combines more readily with allergens without releasing histamine. The goal is to keep blocking the level of IgE by keeping the level of IgG high. Allergen- specific T suppressor cells develop with immunotherapy.

20. What is one of the most significant factors in determining when to start ART in a patient with HIV infection? a. Whether the patient has high levels of HIV antibodies b. Confirmation that the patient has contracted HIV infection c. The patient's readiness to commit to a complex, lifelong, uncomfortable drug regimen d. Whether the patient has a support system to help manage the treatment regimen and costs

c. Guidelines for initiating ART are being updated continuously because of the development of alternative drugs and problems with long- term side effects and compliance with regimens. Whenever treatment is started, an important consideration is the patient's readiness to initiate ART because adherence to drug regimens is a critical component of the therapy and preventing drug resistance.

5. How does interferon help the body's natural defenses? a. Directly attacks and destroys virus-infected cells b. Augments the immune response by activating phagocytes c. Induces production of antiviral proteins in cells that prevent viral replication d. Is produced by viral infected cells and prevents the transmission of the virus to adjacent cells

c. Interferon is antiviral by reacting with viruses and inducing the formation of an antiviral protein that mediates antiviral action of interferon by altering the cell's protein synthesis and preventing viral replication. It also may activate macrophages, neutrophils, and natural killer cells.

14. Why do opportunistic diseases develop in a person with AIDS? a. They are side effects of drug treatment of AIDS. b. They are sexually transmitted to people during exposure to HIV. c. They are characteristic in people with stimulated B and T lymphocytes. d. These infections or tumors occur in a person with an incompetent immune system.

c. P. jiroveci infection is characterized by pneumonia with a dry, nonproductive cough, hypoxemia, and other symptoms. Cryptococcus infection may cause fungal meningitis. Non-Hodgkin's lymphoma is diagnosed by lymph node biopsy. Cytomegalovirus infection is characterized by viral retinitis, stomatitis, esophagitis, gastritis, or colitis.

18. The "rapid" HIV antibody testing is performed on a patient at high risk for HIV infection. What should the nurse explain about this test? a. The test measures the activity of the HIV and reports viral loads as real numbers. b. This test is highly reliable, and in 5 minutes the patient will know if HIV infection is present. c. If the results are positive, another blood test and a return appointment for results will be necessary. d. This test detects drug-resistant viral mutations that are present in viral genes to evaluate resistance to antiretroviral drugs.

c. The "rapid" test is highly reliable and results are available in about 20 minutes. However, if results are positive from any testing, blood will be drawn for HIV viral load testing and another visit will be necessary to obtain the results of the additional testing and plan for care. CD4+ T cell counts are not used for screening but rather are used to monitor the progression of HIV infection, and new assay tests measure resistance of the virus to antiviral drugs.

13. What describes the occurrence of a type IV or delayed hypersensitivity reaction? a. Antigen links with specific IgE antibodies bound to mast cells or basophils releasing chemical mediators b. Cellular lysis or phagocytosis through complement activation following antigen-antibody binding on cell surfaces c. Sensitized T lymphocytes attack antigens or release cytokines that attract macrophages that cause tissue damage d. Antigens combined with IgG and IgM too small to be removed by mononuclear phagocytic system deposit in tissue and cause fixation of complement

c. When sensitized T lymphocytes attack antigens or release cytokines that attract macrophages and cause tissue damage, a type IV or delayed hypersensitivity reaction is occurring with transplant rejections as well as contact dermatitis, some drug sensitivity reactions, and hypersensitivity reactions to bacterial fungal and viral infections. Type I reactions occur when antigens link with specific IgE antibodies bound to mast cells of basophils and release chemical mediators. Type II reactions occur when cellular lysis or phagocytosis occurs through complement activation after antigen-antibody binding on cell surfaces. Type III reactions occur when the antigens combined with IgG and IgM are too small to be removed by the mononuclear phagocytic system and are deposited in tissue and cause complement activation.

25. What is the most common cause of secondary immunodeficiency disorders? a. Chronic stress b. T-cell deficiency from HIV c. Drug-induced immunosuppression d. Common variable hypogammaglobulinemia

c. Drug-induced immunosuppression with antineoplastic agents and corticosteroids is the most common cause of secondary immunodeficiency. Chronic stress and human immunodeficiency virus (HIV) may cause secondary immunodeficiency, but they are not the most common causes. Primary immunodeficiency is caused by common variable hypogammaglobulinemia

29. The patient has received a bone marrow transplant. Soon after the transplant, there is a rash on the patient's skin. She says her skin is itchy and she has severe abdominal pain. What best summarizes what is happening to the patient and how she will be treated? a. Graft rejection occurring; treat with different immunosuppressive agents b. Dry skin and nausea are side effects of immunosuppressants; decrease the dose c. Transplanted bone marrow is attacking her tissue; prevent with immunosuppressive agents d. Dry skin from the dry air and nausea from the food in the hospital; treat with humidifier and home food

c. Graft-versus-host disease (GVHD) is occurring as the graft is rejecting the host tissue, which usually manifests in a pruritic or painful skin rash; in the GI tract with diarrhea, severe abdominal pain, GI bleeding, and malabsorption; or in the liver with mild jaundice, elevated liver enzymes, or coma. GVHD is more effectively prevented with immunosuppressive agents than treated.

24. Before the patient receives a kidney transplant, a crossmatch test is ordered. What does a positive crossmatch indicate? a. Paternity and predicts risk for certain diseases b. Tissue type match for a successful transplantation c. Racial background and predicts risk for certain diseases d. Cytotoxic antibodies to the donor, which contraindicate transplanting this donor's organ

d. A crossmatch mixes recipient serum with donor lymphocytes. A positive crossmatch shows that the recipient has cytotoxic antibodies to the donor and this organ cannot be transplanted without hyperacute rejection occurring. A negative crossmatch indicates that it is safe to do the transplant. The other options are not correct.

23. Priority Decision: A patient diagnosed with HIV 1 year ago has no symptoms of HIV- related illness and does not want to start ART at this time. What is the best nursing intervention for the patient at this stage of illness? a. Assist with end-of-life issues b. Provide care during acute exacerbations c. Provide physical care for chronic diseases d. Teach the patient about immune enhancement

d. After a patient has positive HIV antibody testing and is in acute disease, the overriding goal is to keep the viral load as low as possible and to maintain a functioning immune system. The nurse should provide teaching regarding ways to enhance immune function (e.g., nutrition, vaccinations, rest and exercise, stress reduction) to prevent the onset of opportunistic diseases in addition to teaching about the spectrum of the infection, options for care, signs and symptoms to watch for, ways to prevent HIV spread, and ways to adhere to treatment regimens when ART drugs are initiated. The asymptomatic stage is too early for the other options.

12. A 69-year-old woman asks the nurse whether it is possible to "catch" cancer because many of her friends of the same age have been diagnosed with different kinds of cancer. In responding to the woman, the nurse understands that which factor increases the incidence of tumors in older adults? a. An increase in autoantibodies b. Decreased activity of the bone marrow c. Decreased differentiation of T lymphocytes d. Decreased size and activity of the thymus gland

d. Aging has a pronounced effect on the thymus, which decreases in size and activity, leading to a decline in T cells and cell-mediated immunity and increased T-cell differentiation and memory T cells. A decrease in T cells is responsible for decreased tumor surveillance, resulting in an increase in cancer. B cell activity also declines with advancing age, but the bone marrow is relatively unaffected by increasing age. Circulating autoantibodies increase and are a factor in autoimmune diseases.

13. Which finding supports the diagnosis of acquired immunodeficiency syndrome (AIDS) in the person with HIV? a. Flu-like symptoms b. Oral hairy leukoplakia c. CD4+ T cells 200-500/μL d. Cytomegalovirus retinitis

d. Cytomegalovirus retinitis could be an opportunistic viral infection that occurs when AIDS is diagnosed. Flu-like symptoms occur in the acute HIV infection stage. CD4+ T cells drop to 200 to 500/μL, and oral hairy leukoplakia is seen in the symptomatic infection stage of HIV.

8. Which immunoglobulin is responsible for the primary immune response and forms antibodies to ABO blood antigens? a. IgA b. IgD c. IgG d. IgM

d. IgM immunoglobulin is predominant in the primary immune response and produces antibodies against ABO blood antigens. IgA lines mucous membranes and protects body surfaces. IgD, on lymphocyte surface, assists in the differentiation of B lymphocytes. IgG crosses the placenta and is responsible for the secondary immune response.

22. Prophylactic measures that are routinely used as early as possible in HIV infection to prevent opportunistic and debilitating secondary problems include administration of a. isoniazid to prevent tuberculosis. b. zoster virus vaccination to prevent shingles. c. trimethoprim/sulfamethoxazole for toxoplasmosis. d. vaccines for pneumococcal pneumonia, influenza, and hepatitis A and B.

d. Pneumococcal pneumonia, influenza, and hepatitis A and B vaccines should be given as early as possible in HIV infection while there is still immunologic function. Isoniazid is used for 9 to 12 months only if a patient has reactive purified protein derivative (PPD) > 5 mm, has had high-risk exposure, or has prior untreated positive PPD. Zoster virus vaccination is not recommended for patients with HIV. Trimethoprim/sulfamethoxazole is initiated when CD4+ T cell count is < 200/μL or when there is a history of PCP.

28. What are the most common immunosuppressive agents initially used to prevent rejection of transplanted organs? a. Cyclosporine, sirolimus, and muromonab-CD3 b. Prednisone, polyclonal antibodies, and cyclosporine c. Azathioprine, mycophenolate mofetil, and sirolimus d. Tacrolimus, prednisone, and mycophenolate mofetil

d. Standard immunotherapy involves the use of 3 different immunosuppressants that act in different ways: a calcineurin inhibitor (tacrolimus, cyclosporine), a corticosteroid, and the antimetabolite mycophenolate mofetil. Although cyclosporine is still used, tacrolimus is the most frequently prescribed calcineurin inhibitor. Polyclonal antibodies are used for induction immunosuppression and acute rejection. Azathioprine (Imuran) is similar to mycophenolate mofetil, and they cannot be taken together.

4. Which T lymphocytes are involved in direct attack and destruction of foreign pathogens? a. Dendritic cells b. Natural killer cells c. T helper (CD4) cells d. T cytotoxic (CD8) cells

d. T cytotoxic cells directly attack antigens on the cell membrane of foreign pathogens and release cytolytic substances that destroy pathogens. Dendritic cells primarily capture antigens at sites of contact with the external environment and then transport the antigen to a T cell with specificity for the antigen. Natural killer cells are involved in cell- mediated immunity but are not considered T lymphocytes. T helper cells are involved in the regulation of cell-mediated immunity and humoral antibody response.

12. Which characteristic corresponds with the acute stage of HIV infection? a. Burkitt's lymphoma b. Temporary fall of CD4+ T cells c. Pneumocystis jiroveci pneumonia d. Fever, sore throat, and lymphadenopathy

d. The symptoms of acute HIV infection occur 2 to 4 weeks after initial infection, when the CD4+ T cell counts fall temporarily but quickly return to baseline levels. Symptoms include a mononucleosis-like syndrome of fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, and/or a diffuse rash. Some people develop neurologic complications. Burkitt's lymphoma and Pneumocystis jiroveci pneumonia (PCP) are 2 of the opportunistic diseases that can occur in acquired immunodeficiency syndrome (AIDS). Persistent fevers and drenching night sweats occur in the symptomatic infection stage

20. A nurse develops contact dermatitis after wearing latex gloves. What accurately describes this? a. This demonstrates a type I allergic reaction to natural latex proteins. b. Use of powder-free latex gloves prevents the development of symptoms. c. Use of oil-based hand cream when wearing gloves prevents latex allergy. d. This demonstrates a type IV allergic reaction to chemicals used in the manufacture of latex gloves.

d. This describes a type IV allergic contact dermatitis that is caused by chemicals used in the manufacturing process of latex gloves. A type I allergic reaction that is a response to the natural rubber latex proteins occurs within minutes of contact with the proteins and may manifest with reactions ranging from skin redness to full-blown anaphylactic shock. Powder-free gloves will avoid respiratory exposure to latex proteins, but nonlatex gloves are more helpful. Avoidance of oil-based hand creams when wearing gloves can also help prevent latex allergic reactions.

16. For the patient with allergic rhinitis, which therapy should the nurse expect to be ordered first? a. Corticosteroids b. Immunotherapy c. Antipruritic drugs d.Sympathomimetic/decongestant drug

d. The best drugs for allergic rhinitis are antihistamines. However, of those listed, minor sympathomimetic/decongestant drugs are used primarily for allergic rhinitis. Nasal corticosteroids may be used for seasonal allergic rhinitis; oral corticosteroids are used briefly if the patient does not get relief from other drugs. Immunotherapy is used when the allergen cannot be avoided and after it is found that drug therapy is not effective. Antipruritic drugs are topical and used to relieve itching.