Med-Surg STUDY GUIDE Chapter 13 Immune Responses & Transplantation

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 drugs

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.

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.