Med surg chap 11&12

The purse is caring for a patient with systemic lupus erythematosus (SLE). The patient complains of severe fatigue, a butterfly rash, joint painWhich nursing intervention(s) is/are most appropriate for this patient? (Select all that apply.)

Assess pain control measures that have helped the patient in the past. Assist the patient with planning rest periods throughout the day. Remind the patient to avoid contact with people who have an infection. Ensure the patient understands the importance of her medication regimen.

Arrange the process of HIV invasion in the proper sequence A. HIV attaches to CD4 receptor sites on T-helper cells. B.Opportunistic infection occurs . C. Infected cell replicates itself millions of times. D. T -helper cells fail to activate phagocytes E.Immune system is unable to respond effectively.

Step 1 A Step 2 C Step 3 D Step 4 E Step 5 B

The nurse explains to a patient with a painful toe that the pain is related to the inflammatory response . What process causes this

Swelling, which compress nerves

difference between hummoral and imediated response

The Humoral immunity is rapid or quick in their action against antigens, while the Cell-mediated immunity show delay though permanent action against any pathogens.

2. The nurse differentiates the humoral response from the cell-mediated response. Which statement about cell-mediated response is true?

The sensitized lymphocytes attack the cell for which they were sensitized

Payers patches are like what

Tonsils for the colon

The nurse is educating a patient about his ciagnosis of stage Hodgkin disease . Which statement indicates that the teaching has been successful ?

Two nodes in my left arm are affected

The school nurse is instructing a group of high school sophomores in safe sex practices . Which practice (s) should the nurse include in her teaching? (Select all that apply.)

Use a condom, practice abstinence, avoid unprotected orogenital sex

Which labs prescribed for systemic lupus patient like to take

WBC, platlet, RBC counts

The nurse is working in trauma and is a unit and is accidentally stuck with an IV needle following venipuncture of the patient. What is the nurse first action

Wash the punctured area with soap and water

The home care is caring for a patient with a severc deficiency disorder. What information about infection prevention most important for the nurse to include in the teaching plan ?

Wash your hands frequently

The nurse is caring for a patient who reports feeling very stressed about her new diagnosis of fibromyalgia. Which response is most beneficial in addressing the patient's stress ?

What worries you the most about your fibromyalgia

What filters blood?

spleen

wasting syndrom is what percent of over blank days

10% & 30days

IgM

5-10 attached to B cells released into plasma in immune response

IgA

5-15 tears saliva mucus breast milk vagina fluid

5. MOPP and ABVD therapy for the treatment of Hodgkin disease are treatment protocols that use which combination of factors

Multiple medications given concurrently

The nurse is caring for a pediatric patient recently diagnosed with severe combined immunodeficiency (SCID ) disease . The nurse determines that teaching has been effective after parent makes which statement?

My child should not attend daycare

14. The nurse is educating a patient with lymphoma. Which statement indicates that the patient correctly differentiates Hodgkin lymphoma (HL) and non-Hodgkin lymphoma ( NHL)

Non-Hodgkin lymphoma is less predictable and can spread faster

16. The nurse is assessing a patient's lymph nodes. Which finding would alert the nurse to the possibility of the patient having non-Hodgkin's lymphoma (NHL)?

Noncontinguouos englarged lymph nodes

18. The mother of a young child voices concern about immunizations for her child. Which response is best?

"Immunization is generally a safe method of avoiding certain diseases and the complications that go along with these diseases."

17. The nurse is evaluating the patient's understanding of his new diagnosis of rheumatoid arthritis. Which statement reflects an understanding of the disease process?

"My body produces an immune response to my own cells and tissues.

IgM

0.2 attached to B cells

IgE

0.5 produced by plasma cells in mucus and tonsils

The nurse is caring for an immune compromised patient The patient displays a low-grade fever and complains of a burning and shooting pain, along with itching and tinglisg, that progresses from the clavicle to the scapula . The nurse suspects that the patien will undergo evaluation for which infection?

Shingles

IgG

75-85 blood plasma

Place the events of the complement system of proteins in the correct sequence. A.Antibodies attack the antigen. b. Break in cell wall allows salt to enter antigen cell. C.Antigen swells and bursts. D.Water enters the antigen cell. E. Proteins embed in cell wall of antigen .

A E B D C

7. Which analogy best describes the action of killer T cells?

A mad hornet flying through circulating fluids seeking and killing antigens

&The nurse is performing an assessment on a patient admitted for diagnostic testing to rule out fibromyalgia, Which finding indicates that the patient actually may the disorder ?

A pain response to non painful stimuli

Which patient would the nurse consider to be immunosuppressed? (Select all that apply)

A patient on chemotherapy for cancer A patient using corticosteroids A patient recovering from joint replacement A patient diagnosed with human immunodeficiency virus (HIV)

The nurse is working in a flu immunization clinic. Which situation would require a postponement of immunization ?

A patient received immune globulin 2 weeks ago

6. The nurse is preparing a presentation on the inflammatory response. While preparing a cartoon picture of lysis, the nurse correctly draws which scenario ?

A phagocyte eating an antigen

11. A vaccination or immunization gives a patient which type of immunity

Active aquifer immunity

difference between active and passive immunuty

Active immunity is attained by exposure to a pathogen. This leads to the production of antibodies in the body. The antigens present on the surface of the pathogens act as markers that bind to the antibodies. Passive immunity is acquired when antibodies are introduced into the body from an external source (usually through vaccines) . It provides a quick response to the infection.

4. The nurse is caring for an immunosuppressed patientWhich care considerations should the murso include? (Select all that apply)

Adhere to Standard Precautions. Avoid bringing potted plants into the patient's room. Employ reverse isolation. Use filters on air conditioner vents.

The patient scheduled for a computed tomography (CT) scan with contrast medium questions the nurse why the technologist asked her if she had any food allergies . Which response by the nurse is correct ?

Allergies to shellfish can be a problem because shellfish and CT scan dye are iodine based

The nurse has just administered new antibiotic to a patient. Which manifestation is the best early indicator that the patient may experiencing an anaphylactic reaction ?

Angioedema

The nurse is educating a patient with erythematosos (SLE), Which mformation in most important for the nurse include in the teaching plan ?

Apply fragrance free lotions to dry areas twice daily

3. Which type of lymphocytes actually produces either sensitized lymphocytes or antibodies?

B lymphocytes

B cells produced in

Bone marrow

If patient gets antibiotics and face gets red and swollen

Call rapid response

Nurse should add special caution to the patient teaching with HIV infection that has a blank house pet

Cat

Which conditions that can cause immune deficiency select all

Chemotherapy, viral infections, smoking, malnutrition

After assessing a patient, the nurse suspects that the patient has an abscessed tooth. Which assessment finding confirms that the immune system is fighting the abscess ?

Enlarged cervical lymph node

After influenza immunization , the patient complains of shortness of breath, breaks out in hives, and begins to twitch. Which ordered medication should the nurse give first ?

Epinephrine injection

The industrial nurse should teach all middle-aged employees to receive a tetanus booster how often?

Every 10 years

When collecting data a patient suspected of having an immune deficiency, which factor) should be included ? (Select all

Family history of immune disorder, age, alcohols use, exposure to HIV

What assists in immune action

Garlic

difference in hiv 1 and 2

HIV-1 is the most common type of HIV and accounts for 95% of all infections, whereas HIV-2 is relatively uncommon and less infectious. HIV-2 is mainly concentrated in West Africa and the surrounding countries. HIV-2 is less fatal and progresses more slowly than HIV-1

During assessment of the patient diagnosed with systemic lupus erythematosus (SLB) which sign * (s) and symptoms would the nurse expect to find? (Select all that apply.)

Hair loss,mouth sores, fatigue, rashes

The nurse is providing teaching to a patient who has undergone a liver transplant. Which statement by the need for further patient teaching?

I will need to take medicines to boost my immune system for the next year

A patient has been exposed to an allergen resulting in a hypersensitivity reaction. The nurse correctly recognizes that which immunoglobulin has been triggered ?

IgE

The nurse is reviewing laboratory results of a patient who had surgery 2 days ago. The nurse notes that the C- reactive protein is elevated. What potential problem does this finding indicate?

Impending infection

The outpatient clinic nurse is collecting a health history on a 78-year-old patient who has a history of emphysema. Which annual immunization is most important for the patient to receive?

Influenza

The nurse is aware that unlike dogs, humans do not contract such diseases as distemper. Which type of immunity explains this protection

Innate immunity

12. How does long-term alcohol abuse lead to alteration in the immune system?

It impaired the ability of B lymphocytes to produce antibodies

Which ways in which antibodies can protect the body by either destroying or inactivating a particular antigen ? Select all

Mechanically harming the antigen Activating the complement system Releasing chemicals that alter the environment of the antigen

The nurse is preparing to write a care plan for the patient with fibromyalgia. Which problem/nursing diagnosis best addresses this disorder

Pain chronic

Which statements about passive immunity are true? (Select all that apply.

Passive immunity prevents further tissue damage. Passive immunity provides temporary immunity from the disease.

The young father tells the industrial nurse at work that is afraid he will give his 2-week-old baby his cold . The surse can assure him that the baby is protected by which type of immunity ?

Passive natural immunity

A patient with an immune deficiency disorder has been admitted to the medical unit due to a current infection and weight loss of 12% of his body weight . Which nutritional intervention is most appropriate for this patient ?

Protein

Which scenario explains how a patient can be protected by passive artificial immunity?

Receiving an injection with immune globulin

The nurse is teaching about changes in the immune system that result the aging process. Which change should the nurse include

Reduced capillary action

the nurse is caring for a patient with suspected Hodgkin's lymphoma (HL) . For confirmation of this diagnosis, the nurse understands that the patient's blood work would reveal which type of abnormal cell?

Reed- sternberg R-S cells

Patient has been diagnosed with lymphoma patient has what cells in blood

Reeds stynburg cells RS

Autoimmune diseases

Rhuitoid arthritis, inflammatory bowel disease, multiple sclorosis