Med Surg: Chapter 36: Nursing Assessment: Immune Function: PREPU
Which of the following is accurate regarding acquired immunity? Select all that apply. A An immunologic response acquired during life but not present at birth B Also know as innate immunity C Usually develops as a result of exposure to an antigen through immunization D A nonspecific immunity present at birth E Can develop by contracting a disease
A, C, E
Which of the following is a center for immune cell proliferation? A Pancreas B Lymph node C Spleen D Liver
B The lymph nodes remove foreign material from the lymph system before it enters the bloodstream. They are centers for immune cell proliferation.
A 48-year-old patient has had multiple sclerosis for 15 years, and she is receiving interferon injections. What is the purpose of interferon injections? A To modify the immune response by suppressing antibody production and cellular immunity B To complement components, prostaglandins, leukotrienes, and other inflammatory mediators C To give rise to numerous cell types able to form tissues in three germ layers D To complement receptors and, as a result, play an important role in the clearance of antigens
A
A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised? A Specific immunity B Passive immunity C Natural immunity D Adaptive immunity
C
A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This is important for which reason? A Blood products cause lower antibody titers. B Blood products cause a high risk for exposure to HIV. C Exposure to foreign antigens may cause altered immune function. D Blood products cause a high risk for hepatitis B.
C
A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function? A Surgical removal of the appendix B Previous organ transplantation C History of radiation therapy D Surgical history of a splenectomy
A
When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask? A"Have you ever received a blood transfusion?" B "When was your last menstrual period?" C "Do you have abdominal pain or discomfort?" D "Have you ever been treated for a sexually transmitted infection?"
A
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte. A Cytotoxic T cell B Suppressor T cell C Helper T cell D Memory T cell
A The cytotoxic T cells (also known as killer T cells) attack the antigen directly and release cytotoxic enzymes and cytokines.
What type of immunoglobulin does the nurse recognize that promotes the release of vasoa ctive chemicals such as histamine when a client is having an allergic reaction? A IgE B IgM C IgG D IgA
A
A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby: A Lymphocytes migrate to areas of the lymph node B. B-lymphocytes respond to a specific antigen C Antibodies are released into the bloodstream D Antibodies reside in the plasma
A
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? A Phagocytosis B Cellular immune response C Antibody response D Apoptosis
A
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell? A Lymphocyte B Neutrophil C Monocyte D Basophil
A
All the following items are related to cancer. Which does not affect the immune system? A Altered production of lymphocytes B Chemotherapy C Diagnostic tests for cancer D Radiation treatment
C
A client presents at the clinic with an allergic disorder. The client asks the nurse what an "allergic disorder" means. What would be the nurse's best response? A. "It is a hyperimmune response to something in the environment that is usually harmless." B. "It is a harmless reaction to something in the environment." C. "It is a muted response to something in the environment." D. "It means you are very sensitive to something inside of yourself."
A
A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have? A The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC). B The nurse ensures a written consent is obtained prior to testing. C The nurse will call the client with the results of the test. D The nurse should send the client to have the blood drawn without informing him about the specific screening test
B
An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect? A Artificially acquired active immunity B Natural passive immunity C Naturally acquired active immunity D Passive immunity
C
The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following? A. Serum, which depletes the body's store of glucagon B. Plasma, which depletes the body's store of calcitonin C. Serum, which depletes the body's store of immunoglobulins D. Plasma, which depletes the body's store of catecholamines
C
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications? A Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive. B Give the client one medicine at a time and observe for allergic reactions. C Call the pharmacy and let them know the client has several drug allergies. D Administer the medications that the physician ordered.
A
A client comes into the emergency department reporting difficulty walking and loss of muscle control in the arms. Once the nurse begins the physical examination, which assessment should be completed if an immune dysfunction in the neurosensory system is suspected? A Assess for hepatosplenomegaly by measuring abdominal girth B Review the urinalysis report for hematuria C Assess for ataxia using the finger-to-nose test and heel-to-shin test D Assess joint mobility using passive range of motion.
C
At 39 weeks' gestation, a pregnant client visits the physician for a scheduled prenatal checkup. The physician determines that the fetus has developed an infection in utero and sends the client for an emergency cesarean delivery. The client is very concerned about the health of her unborn child. Based on knowledge of the immune system, the delivery room nurse explains about which immunoglobulin that will be increased in the fetus at the time of birth and will be actively fighting the infection? A IgD B IgG C IgA D IgM
B IgG composes 75% of total immunoglobulin. It appears in serum and tissues, assumes a major role in bloodborne and tissue infections, and crosses the placenta.
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she had the measles when she was a little girl. What immunity to measles develops after the initial infection? A Naturally acquired passive immunity B Artificially acquired active immunity C Naturally acquired active immunity D Artificially acquired passive immunity
C Immunity to measles that develops after the initial infection is an example of naturally acquired active immunity. Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated toxin), whereas passive immunity develops when ready-made antibodies are given to a susceptible client.
A client has begun sensitivity testing to determine the allergen which caused an anaphylactic reaction 3 weeks ago. In scratch testing, which part of the body is more sensitive to allergens? A forearm B upper arm D chest D back
D
The body has several mechanisms to fight disease, one of which is sending chemical messengers. The messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response. Which messenger enables cells to resist viral replication and slow viral replication? A tumor necrosis factor B colony-stimulating factor C interleukins D interferons
D
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system? A Stem cells B Red blood cells C Cytokines D Lymphoid tissues
D
A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to: A. acidosis because the spleen maintains acid-base balance. B. infection because the spleen removes bacteria from the blood. C. bleeding because the spleen synthesizes vitamin K. D. anemia because the spleen produces red blood cells.
B
The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function? A. Surgical history of a partial gastrectomy B Previous organ transplantation C Negative history for radiation therapy D Surgical removal of the appendix
B
