Module 7: Immune EAQ (MEDSURG)

A nurse is caring for a patient with systemic lupus erythematosus. What is the pathophysiologic response that the disease has on the patient? 1 Autoimmunity 2 Hypersensitivity 3 Immunodeficiency 4 Delayed hypersensitivity

ANS 1 Rationale Autoimmunity occurs when the body identifies self proteins as foreign substances and causes cellular and tissue damage. Hypersensitivity is an exaggerated immune response to specific products. Immunodeficiency results from an incompetent immune system, which can be caused by pathogens, medications, and many other factors. Delayed hypersensitivity is a type of hypersensitivity reaction that takes 24 to 48 hours to occur. p. 206

A healthy older adult patient is requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving? Select all that apply. 1 Shingles 2 Pneumonia 3 Meningococcal 4 Haemophilus influenzae type b (Hib) 5 Measles, mumps, and rubella (MMR)

ANS 1,2 Rationale The patient should receive the shingles (herpes zoster) vaccine, Pneumovax, and influenza. Meningococcal, Hib, and MMR vaccinations do not apply to this patient. Meningococcal vaccination is recommended for adults at risk (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). Adults born before 1957 generally are considered immune to measles and mumps. Hib vaccination is considered only for adults with selected conditions (e.g., sickle cell disease, leukemia, human immunodeficiency virus [HIV] infection, or for those who have anatomic or functional asplenia) if they have not been vaccinated previously. p. 196

The nurse is comparing cell-mediated immunity and humoral immunity. Which of these are characteristics of humoral immunity? Select all that apply. 1 Antibodies are produced. 2 Involves B lymphocyte cells. 3 Involves T lymphocyte cells and macrophages. 4 Examples include anaphylactic shock and transfusion reaction. 5 Examples include destruction of cancer cells and graft rejection.

ANS 1,2,4 Rationale Humoral immunity involves B lymphocyte cells and produces antibodies. Examples include anaphylactic shock, atopic diseases, transfusion reaction, and bacterial infections. The other responses reflect cell-mediated immunity. Humoral immunity does not involve T lymphocytes and macrophages (cell-mediated immunity does). Cancer cell destruction and graft rejection are examples of cell-mediated immunity.

Which nursing interventions should be implemented when caring for a patient who is taking immunosuppressive therapy? Select all that apply. 1 Place the patient in a private room 2 Advise the patient to avoid people who are sick 3 Encourage the patient to reduce daily fluid intake 4 Encourage consumption of fresh fruits and vegetables 5 Advise the patient to report any symptoms of acute illness

ANS 1,2,5 Rationale The patient should be placed in a private room and be advised to avoid people who are sick. The patient should also report any symptoms of acute illness. The consumption of fresh fruits and vegetables may introduce pathogens to the patient; this action should be discouraged. Encouraging the patient to reduce his or her daily fluid intake is not advised unless otherwise indicated, because the patient needs the fluid intake for adequate perfusion and kidney function. p. 211

The nurse is educating a patient who is taking calcineurin inhibitors in order to prevent organ rejection after organ transplantation. Which side effects should the nurse be sure to include when educating the patient about the medication? Select all that apply. 1 Hirsutism 2 Peptic ulcer 3 Hypertension 4 Nephrotoxicity 5 Bone marrow suppression

ANS 1,3,4 Rationale Calcineurin inhibitors are a class of immunosuppressant drugs that act on the T helper cells to prevent production and release of interleukin-2 and β-interferon. The side effects associated with the use of calcineurin inhibitors include hirsutism, or abnormal growth of hair on a woman's face and body, as well as hypertension and nephrotoxicity. Peptic ulcer is a side effect of corticosteroid usage. Bone marrow suppression is a side effect of azathioprine.

The nurse is educating an older adult patient about immunizations. Which type of immunity is provided by immunizations? 1 Innate 2 Active 3 Natural 4 Passive

ANS 2 Rationale Active immunity is exposure to a pathogen to cause an antigen response; this type of immunity can be gained by immunization. Innate immunity is present at birth; another term for this type of immunity is natural. Passive immunity crosses the placenta or through the colostrum.

A nursing instructor is lecturing on immunoglobulins. Which common immunoglobulin would the students expect to find in tears and colostrum? 1 IgE 2 IgA 3 IgG 4 IgM

ANS 2 Rationale IgA is present in tears and colostrum. IgE and IgG are present in plasma and interstitial fluids. IgM is present in plasma. p. 197

Which type of immunity is present at birth? 1 Active 2 Innate 3 Passive 4 Acquired

ANS 2 Rationale Innate immunity is present at birth. Passive immunity results from the introduction of antibodies from another organism, as in from a mother to her fetus. Acquired immunity can be either passive or active. Active immunity is the result of exposure to a pathogen in order to develop immunity to it, as in the case of vaccination. p. 191

The nurse is performing an assessment on an older adult patient. Which statement regarding age-related changes within the immune system indicate a lack of understanding on the part of the nurse? 1 "Thymic involution occurs with aging." 2 "The bone marrow will change with age." 3 "Older adults are more susceptible to infections." 4 "Both T and B cells show deficiencies in activation."

ANS 2 Rationale The functions of the immune system decline with advancing age, but bone marrow remains relatively unaffected. If the nurse states that bone marrow changes with aging, this indicates a lack of understanding. Thymic involution occurs with aging due to the decreased functional activity of the thymus. Older people are more susceptible to infections because the function of the immune system declines with increasing age. Both T and B cells show deficiencies in activation with increasing age due to reduced immune activity in the body. p. 196

Which functions does the nurse know are part of the normal immune response? Select all that apply. 1 Sepsis 2 Defense 3 Mobilization 4 Surveillance 5 Homeostasis

ANS 2, 4,5 The functions of the normal immune response include defense, homeostasis, and surveillance. Sepsis is the result of a serious infection, and mobilization is not part of the normal immune response. pp. 191-192

A nurse is teaching at a health fair about immunizations. How will this nurse educate the people at the fair about the benefits of immunization? Select all that apply. 1 It helps in building a short-term immunity. 2 It reduces and can possibly eliminate diseases like polio. 3 It can prevent disability and death from certain infectious diseases. 4 It can help control the spread of infections within the community. 5 It should be given with immunosuppressive therapy to reduce the side effects.

ANS 2,3,4 Artificial active acquired immunization is obtained from vaccinations. Immunization helps to control the spread of infections. It prevents disability and death from infectious diseases and reduces the risk of diseases like polio by producing immunity against them. Immunity developed through immunization takes time to develop but is usually long-lasting. Also, immunization should not be given with immunosuppressive therapy, because it may prove fatal. p. 192

Which immune response is an autoimmune disorder? 1 Anaphylaxis 2 Atopic reaction 3 Hypersensitivity 4 Contact dermatitis

ANS 3 Rationale A hypersensitive reaction includes autoimmune diseases in which the body fails to recognize self-proteins and reacts against self-antigens. Anaphylaxis occurs when mediators are released systemically. Contact dermatitis is a delayed hypersensitivity reaction involving the skin. An atopic reaction is a sensitivity to environmental allergens. p. 197

The nurse is administering tacrolimus to a patient. Which information about this medication would the nurse be sure to include during patient education? 1 Take this medication on an empty stomach. 2 This medication has very few side effects. 3 Avoid eating or drinking products with grapefruits while taking this medication. 4 Flu-like symptoms will develop in the first few days of treatment.

ANS 3 Rationale A substance in grapefruit and grapefruit juice prevents metabolism of these drugs. Consuming grapefruit or grapefruit juice while using tacrolimus could increase its toxicity. Tacrolimus can be taken with food or on an empty stomach; there is no specification. The medication does have significant side effects, including nephrotoxicity, that the patient should be taught. A flu-like syndrome occurs during the first few days of treatment when taking monoclonal antibodies, not tacrolimus, because of cytokine release. p. 209

Which cells are involved in humoral immunity? 1 Neutrophils 2 T lymphocytes 3 B lymphocytes 4 Natural killer cells

ANS 3 Rationale B lymphocytes are involved in humoral immunity. Natural killer cells are involved in cell-mediated immunity. Neutrophils are mature white blood cells. T lymphocytes are involved in cell-mediated immunity. p. 196

A nurse is administering mycophenolate mofetil as a part of triple immunosuppressive therapy for a posttransplant patient. Which is the most important nursing intervention? 1 Give large doses as intravenous (IV) bolus. 2 Reconstitute the drug in normal saline. 3 Administer the drug over 2 or more hours. 4 Educate the patient about gastrointestinal side effects.

ANS 3 Rationale The most important nursing intervention when administering mycophenolate mofetil is to infuse this medication over 2 or more hours. Giving the drug slowly helps to decrease the side effects. The drug should never be given as an IV bolus and should always be reconstituted in D 5W. Thereafter, the nurse may educate the patient about the gastrointestinal side effects. p. 209

The nurse is caring for a patient scheduled for a kidney transplant. What education should the nurse provide the patient in preparation for the transplant? Select all that apply. 1 Avoid all exercise, work, and sports activities. 2 Production of urine will be delayed after surgery. 3 Immunosuppressive drugs daily will be required. 4 Transplantation will be performed only if crossmatching is negative. 5 Symptoms of rejection include a decrease in temperature and blood pressure.

ANS 3,4 Rationale Immunosuppressive agents are administered to reduce the immune system's tendency to reject the transplanted organ. A crossmatch uses serum from the recipient mixed with donor lymphocytes to test for any preformed anti-HLA antibodies to the potential donor organ. A negative crossmatch indicates that no preformed antibodies are present, and it is safe to proceed with transplantation. Urine production occurs almost immediately. If the transplant is rejected, the patient may experience a rise in temperature and blood pressure due to fluid retention. Although recreation and exercise are encouraged, strenuous sports activities should be strictly avoided. pp. 207-208

Which type of immunity occurs when a patient receives a hepatitis B immune globulin injection? 1 Active-natural 2 Passive-active 3 Active-artificial 4 Passive-artificial

ANS 4 Rationale The patient receives passive-artificial immunity when given an immune globulin, because exposure via blood products is considered passive-artificial. Passive and active immunity are two types of immunity, not one type. Active-natural immunity occurs when a patient has natural contact with the antigen. Active-artificial immunity occurs when a patient is immunized with an antigen, for instance via vaccine. p. 192

Which immunoglobulin has the highest total serum concentration? 1 IgA 2 IgD 3 IgE 4 IgG

ANS 4 Rationale The serum concentration of IgG is 78%, which is the highest of these immunoglobulins. IgA has a serum concentration of 15%. IgD has a serum concentration of 1%. IgE has a serum concentration of 0.002%. p. 194