Chapter 23 My Nursing Test Banks

Tabloski Gerontological Nursing, 3/e
Chapter 23

Question 1

Type: MCSA

What does the nurse recognize as the reason for the immune system to develop long-lasting protection against specific antigens?

1. Memory

2. Tolerance

3. Specificity

4. Self-recognition

Correct Answer: 1

Rationale 1: Memory means that the immune system has the capacity to develop long-lasting protection against specific invaders. A residual set of cells that are specific to each antigen remains in the body, to be stimulated when the antigen presents itself at a later time. Each successive time the antigen is encountered, a quicker and more intense reaction is stimulated by the immune system in the healthy older person.
Reference: Page 652

Rationale 2: Tolerance is another term for self-recognition and is the ability of the immune system to differentiate between substances that are part of the persons body and those that are foreign.
Reference: Page 652

Rationale 3: Specificity refers to the ability of the immune system to react with a particular immune response to one antigen. Each new antigen stimulates a different immune response.
Reference: Page 652

Rationale 4: Self-recognition or tolerance is the ability of the immune system to differentiate between substances that are part of the persons body and those that are foreign.
Reference: Page 652

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe the three unique characteristics of the immune system.

Question 2

Type: MCSA

Why should the nurse remind an older patient to receive a pneumococcal vaccination at the age of 65?

1. Increased production of IgE

2. Decline in antibody response

3. Decreased antibody production to self

4. Increased speed of the cellular response

Correct Answer: 2

Rationale 1: Over time, the secondary immune response may also show changes. The number of B cells in the circulation decreases in some individuals. As a result, tissues are slower to repair and are more vulnerable to disease, especially infections. A decline in the production of IgE leads to a decrease in allergic or hypersensitivity reactions.
Reference: Pages 656, 666

Rationale 2: To prevent serious complications, all people 65 years of age and older should receive a pneumococcal vaccine. Antibody response is often lower in the older person and may decline after 5 to 10 years.
Reference: Pages 656, 666

Rationale 3: A sign of aging in the immune system is an increase in antibody production against self.
Reference: Pages 656, 666

Rationale 4: A sign of aging in the immune system is an overall decline in the speed of the cellular response.
Reference: Pages 656, 666

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Distinguish the similarities, differences, and interactions among the humoral immune response and the cellular immune response.

Question 3

Type: MCSA

The nurse is reviewing the white blood cell count for an older patient. Which white blood cell has the ability for self-recognition, specificity, and memory?

1. Monocytes

2. Neutrophils

3. Lymphocytes

4. Thrombocytes

Correct Answer: 3

Rationale 1: Monocytes are white blood cells that become large phagocytic cells when stimulated and are active in inflammation.
Reference: Page 652

Rationale 2: Neutrophils are white blood cells that directly fight against bacteria.
Reference: Page 652

Rationale 3: Lymphocytes are the primary cells concerned with the development of immunity. Of all white blood cells, only lymphocytes have the ability for self-recognition, specificity, and memory.
Reference: Page 652

Rationale 4: Thrombocytes are not white blood cells but are platelets that are involved in clotting.
Reference: Page 652

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Distinguish the similarities, differences, and interactions among the humoral immune response and the cellular immune response.

Question 4

Type: MCSA

The nurse suspects an older patient is experiencing a type I hypersensitivity response. What did the nurse assess in this patient?

1. A drug reaction causing a rash

2. Reaction after getting a vaccination

3. Anaphylactic reaction after eating shrimp

4. Dermatitis resulting from a response to a brand of soap

Correct Answer: 3

Rationale 1: Type II hypersensitivity responses occur in response to an allergy to drugs.
Reference: Page 660

Rationale 2: Type III hypersensitivity responses include serum sickness.
Reference: Page 660

Rationale 3: Type I hypersensitivity responses occur immediately and include anaphylactic reactions.
Reference: Page 660

Rationale 4: Type IV hypersensitivity responses include allergic contact dermatitis.
Reference: Page 660

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Distinguish the similarities, differences, and interactions among the humoral immune response and the cellular immune response.

Question 5

Type: MCMA

An older patient is diagnosed with asthma. What should the nurse teach the patient about this health problem?

Standard Text: Select all that apply.

1. It is a type I hypersensitivity response.

2. Items that precipitate attacks must be identified.

3. It is not particularly prevalent in the older person.

4. Symptoms of the disorder likely were present earlier in life.

5. Medications to treat may aggravate other medical problems.

Correct Answer: 1,2,4,5

Rationale 1: Asthma is a common hypersensitivity type I problem that is often underdiagnosed in the older person.
Reference: Page 661

Rationale 2: Interventions should be aimed at identifying allergens that precipitate attacks and reducing them in the home.
Reference: Page 661

Rationale 3: Type I hypersensitivity reactions do occur in the older person. Type II hypersensitivity reactions are not particularly prevalent in the older person.
Reference: Page 661

Rationale 4: Patients with asthma are more likely to have had symptoms earlier in life.
Reference: Page 661

Rationale 5: Asthma medications may aggravate coexisting medical conditions.
Reference: Page 661

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Associate the pathology that underlies illnesses associated with both excessive and deficient immune responses.

Question 6

Type: MCMA

An older patient is surprised to learn of the diagnosis of rheumatoid arthritis. What can the nurse explain to the patient about this disorder?

Standard Text: Select all that apply.

1. Antibodies form against the persons own IgG.

2. The onset of the disorder is slower in older adults.

3. It is a delayed hypersensitivity response to an antigen.

4. There can be abnormalities in both B and T immunity cells.

5. Inflammatory process is stimulated by T cells and destroys articular cartilage.

Correct Answer: 1,5

Rationale 1: Rheumatoid arthritis is a type III hypersensitivity response where antibodies form against the persons own IgG causing the complex to be identified as foreign.
Reference: Page 661

Rationale 2: Type IV hypersensitivity responses are slower in older adults.
Reference: Page 661

Rationale 3: Type IV hypersensitivity responses are delayed responses to an antigen.
Reference: Page 661

Rationale 4: Abnormalities in both B and T cells have been seen in people with multiple sclerosis which is theorized to be a type IV hypersensitivity response.
Reference: Page 661

Rationale 5: In rheumatoid arthritis, the inflammatory process is stimulated by infiltrating T cells and gradually destroys articular cartilage.
Reference: Page 661

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Associate the pathology that underlies illnesses associated with both excessive and deficient immune responses.

Question 7

Type: MCSA

What does the nurse realize as the reason for an older patient to be diagnosed with HIV/AIDS late in the disease process?

1. Older patients have improved immunity to fight the infection

2. Older patients are usually less ill with the initial infection than younger patients with HIV/AIDS.

3. Older patients often have symptoms that may be attributed to other conditions associated with age.

4. Older patients are more likely to have contracted the disease from contaminated blood or blood products.

Correct Answer: 3

Rationale 1: The older patient does not have improved immunity to fight the infection. The diagnosis is often made later because the manifestations can be confused with other problems associated with weight and memory loss.
Reference: Page 663

Rationale 2: Older patients are more ill and have higher death rates than younger patients who have HIV/AIDS.
Reference: Page 663

Rationale 3: Since many symptoms of AIDS mimic those of normal aging, such as memory loss, fatigue, and weight loss, physicians can miss a diagnosis of HIV infection.
Reference: Page 663

Rationale 4: Today HIV/AIDS infection is likely to be the result of unprotected sex with an infected person or intravenous illicit drug use because the blood and blood products are tested for HIV.
Reference: Page 663

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Outline the unique characteristics associated with HIV infection in the older person.

Question 8

Type: MCMA

An older patient is diagnosed with a disease caused by a secondary immunodeficiency disorder. For which disorders should the nurse be prepared to plan care?

Standard Text: Select all that apply.

1. HIV

2. Cirrhosis

3. Medications

4. Malnutrition

5. Diabetes mellitus

Correct Answer: 2,3,4,5

Rationale 1: HIV is a primary immunodeficiency disorder.
Reference: Page 665

Rationale 2: Secondary immunodeficiency disorders are a consequence of other disorders or treatment regimens such as cirrhosis.
Reference: Page 665

Rationale 3: Secondary immunodeficiency disorders are a consequence of other disorders or treatment regimens. Many factors can lead to the development of secondary immunodeficiency disorders, including pharmacological factors from medications.
Reference: Page 665

Rationale 4: Secondary immunodeficiency disorders are a consequence of other disorders or treatment regimens. Many factors can lead to the development of secondary immunodeficiency disorders, including nutritional disorders such as malnutrition.
Reference: Page 665

Rationale 5: Secondary immunodeficiency disorders are a consequence of other disorders or treatment regimens such as diabetes mellitus.
Reference: Page 665

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Associate the pathology that underlies illnesses associated with both excessive and deficient immune responses.

Question 9

Type: MCSA

For which older patient should the nurse suspect a decline in the responsiveness of the immune system?

1. 78-year-old patient with pneumonia and temperature of 99.5F

2. 68-year-old patient with a red itchy rash from contact with poison ivy

3. 80-year-old patient with swelling and redness around an abdominal incision

4. 66-year-old patient with 8 mm induration from a mumps skin test 72 hours earlier

Correct Answer: 1

Rationale 1: The febrile response that signals infections may be blunted in the older person. The baseline body temperature in older people is approximately 1F lower than the normal temperature in younger people. A rise in body temperature may not be immediately evident.
Reference: Page 665

Rationale 2: A red itchy rash from poison ivy is an expected immune response.
Reference: Page 665

Rationale 3: Swelling and redness around an incision is an expected immune response to an infected wound.
Reference: Page 665

Rationale 4: An area of induration after a mumps skin test is an expected immune response to exposure to the virus.
Reference: Page 665

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. Identify factors that affect proper immune system function.

Question 10

Type: MCSA

An older patient asks the purpose of receiving an annual flu vaccination if the pneumonia vaccination was received just a few years ago. How should the nurse respond to this patient?

1. That is an error and it is not necessary.

2. Everyone needs a flu vaccination regardless of age.

3. Pneumonia can develop as a complication from the flu.

4. The incidence of flu is higher in older people than younger people.

Correct Answer: 3

Rationale 1: More than 90% of the deaths during previous U.S. influenza epidemics were attributed to pneumonia as a complication of influenza. The vaccine reduces influenza-related morbidity and mortality by 70% to 90% among vaccinated individuals. The need to get a flu vaccination is not in error.
Reference: Page 666

Rationale 2: More than 90% of the deaths during previous U.S. influenza epidemics were attributed to pneumonia as a complication of influenza. The vaccine reduces influenza-related morbidity and mortality by 70% to 90% among vaccinated individuals.
Reference: Page 666

Rationale 3: More than 90% of the deaths during previous U.S. influenza epidemics were attributed to pneumonia as a complication of influenza. The vaccine reduces influenza-related morbidity and mortality by 70% to 90% among vaccinated individuals.
Reference: Page 666

Rationale 4: More than 90% of the deaths during previous U.S. influenza epidemics were attributed to pneumonia as a complication of influenza. The vaccine reduces influenza-related morbidity and mortality by 70% to 90% among vaccinated individuals. It is unknown if the incidence of flu is higher in older people than younger people.
Reference: Page 666

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Identify nursing interventions that can be effective in improving immune status in the older person.

Question 11

Type: MCMA

An older patient is diagnosed with bacteremia. What should the nurse suspect as being the cause of this patients health problem?

Standard Text: Select all that apply.

1. Pneumonia

2. Herpes zoster

3. Antibiotic use

4. Infected leg wound

5. Urinary tract infection

Correct Answer: 1,4,5

Rationale 1: Bacteremia is the introduction of bacteria into the blood stream and can be a complication of pneumonia.
Reference: Page 666

Rationale 2: Herpes zoster is a virus that causes chicken pox and shingles.
Reference: Page 666

Rationale 3: Antibiotic use can cause superinfections in the older patient.
Reference: Page 666

Rationale 4: Bacteremia is the introduction of bacteria into the blood stream and can be caused from an infected leg wound.
Reference: Page 666

Rationale 5: Bacteremia is the introduction of bacteria into the blood stream and can be caused by a urinary tract infection.
Reference: Page 666

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Explain the physiological processes that increase the susceptibility of the older person to infections.

Question 12

Type: MCMA

An older patient is diagnosed with tuberculosis. What should the nurse explain to the patient about this infection?

Standard Text: Select all that apply.

1. It can affect other body tissue.

2. It spreads by airborne transmission.

3. It is a chronic infection of the lungs.

4. It is most controlled in nursing homes

5. Older people are at higher risk for the disease.

Correct Answer: 1,2,3,5

Rationale 1: Tuberculosis is a chronic extrapulmonary infectious disease which means it affects body tissues other than the lungs.
Reference: Page 667

Rationale 2: Tuberculosis spreads from person to person by airborne transmission.
Reference: Page 667

Rationale 3: Tuberculosis is a chronic pulmonary infectious disease.
Reference: Page 667

Rationale 4: Older adults are at increased risk of initial infection, particularly those who reside in nursing homes.
Reference: Page 667

Rationale 5: The number of cases of tuberculosis is highest in people over 65 years of age.
Reference: Page 667

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Explain the physiological processes that increase the susceptibility of the older person to infections.

Question 13

Type: MCSA

What should the nurse explain as the cause for shingles in an older patient?

1. Erysipelas

2. Bacteremia

3. HIV/AIDS

4. Herpes zoster

Correct Answer: 4

Rationale 1: Erysipelas is a superficial cellulitis caused by group A streptococcus.
Reference: Page 667

Rationale 2: Bacteremia is a bacterial infection in the blood.
Reference: Page 667

Rationale 3: HIV/AIDS is caused by the human immunodeficiency virus.
Reference: Page 667

Rationale 4: The reactivation of the herpes zoster virus that has lingered in nerve tissue for years following a chickenpox infection can lead to shingles.
Reference: Page 667

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Explain the physiological processes that increase the susceptibility of the older person to infections.

Question 14

Type: MCSA

An older patient is hesitant to receive a vaccination against shingles because he does not understand what shingles are. What should the nurse explain to this patient?

1. They are seldom painful.

2. They should be treated with antibiotics.

3. They cause vesicular lesions along spinal nerves.

4. They result from reactivation of a herpes simplex virus.

Correct Answer: 3

Rationale 1: Lesions from shingles are usually very painful.
Reference: Page 668

Rationale 2: Shingles are caused by a virus which means antibiotics are ineffective.
Reference: Page 668

Rationale 3: Shingles causes vesicular lesions along spinal nerves, most frequently affecting T3 to L2 nerves and the fifth cranial nerve.
Reference: Page 668

Rationale 4: Shingles is caused by a reactivation of the herpes zoster virus and not the herpes simplex virus.
Reference: Page 668

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Explain the physiological processes that increase the susceptibility of the older person to infections.

Question 15

Type: MCSA

Which action will help reduce the risk of a nosocomial infection in an older patient?

1. Limit the sanitization of equipment.

2. Begin aspiration precautions for dysphagia.

3. Provide antibiotics as prescribed for viral infections.

4. Insert an indwelling urinary catheter for urinary incontinence.

Correct Answer: 2

Rationale 1: Nosocomial infections are those which are acquired in an institution. Equipment should be sanitized to prevent the spread of pathogenic organisms to patients who may have weakened immune systems.
Reference: Page 668

Rationale 2: Nosocomial infections are those which are acquired in an institution. Using aspiration precautions with patients who have dysphagia will decrease the likelihood of aspiration and the pneumonia that often results.
Reference: Page 668

Rationale 3: Inappropriate use of antibiotics, such as prescribing antibiotics for patients who do not have demonstrated bacterial infections leads to the development of resistant strains of bacteria within the institution.
Reference: Page 668

Rationale 4: Indwelling urinary catheters lead to the development of urinary tract infections.
Reference: Page 668

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Explain the physiological processes that increase the susceptibility of the older person to infections.

Question 16

Type: MCMA

The healthcare provider suggests that an older patient take daily vitamin supplements to enhance immunity. On which supplements should the nurse instruct the patient?

Standard Text: Select all that apply.

1. Zinc

2. Iodine

3. Vitamin D

4. Vitamin C

5. Magnesium

Correct Answer: 1,3,4

Rationale 1: Zinc is a micronutrient that helps maintain many body homeostatic mechanisms, including the effectiveness of the immune system. Zinc is required for proper production of many enzymes and proteins in the body, and for cellular proliferation. Zinc deficiency results in impaired immune response and the development of degenerative diseases.
Reference: Page 659

Rationale 2: Iodine is not a vitamin supplement that will enhance immunity.
Reference: Page 659

Rationale 3: Evidence is accumulating on the beneficial effects of vitamin D in improving the health of the immune system.
Reference: Page 659

Rationale 4: Vitamin C contributes to the cellular immune response.
Reference: Page 659

Rationale 5: Magnesium is not identified as a vitamin supplement that will enhance immunity.
Reference: Page 659

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Identify nursing interventions that can be effective in improving immune status in the older person.

Question 17

Type: MCMA

The nurse is preparing a program for senior citizens about the influenza vaccination. Which information should the nurse include in the program?

Standard Text: Select all that apply.

1. A new vaccination is needed annually.

2. The vaccination is given once after the age of 65.

3. It should not be taken if diagnosed with a chronic disease.

4. The only contraindication to the influenza vaccine is an allergy to eggs.

5. Most people who receive the pneumonia vaccination do not need the influenza vaccine.

Correct Answer: 1,4

Rationale 1: The flu virus changes annually necessitating a vaccination every year.
Reference: Page 666

Rationale 2: The vaccination is needed annually. The pneumonia vaccination is given once after the age of 65.
Reference: Page 666

Rationale 3: The flu vaccination should be given to people in high risk groups such as those with a chronic disease.
Reference: Page 666

Rationale 4: The flu vaccination should not be taken by those with an allergy to eggs.
Reference: Page 666

Rationale 5: The flu vaccination is needed to prevent the complication of pneumonia.
Reference: Page 666

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Identify nursing interventions that can be effective in improving immune status in the older person.

Question 18

Type: MCMA

An older patient recovering from pneumonia asks what can be done to stay healthier in the future. What should the nurse include when responding to this patients question?

Standard Text: Select all that apply.

1. Maintain a healthy weight.

2. Restrict the intake of dairy products.

3. Take a daily multivitamin/mineral supplement.

4. See the physician for any signs of an infection.

5. Engage in regular moderate exercise 30 minutes a day, 5 days a week.

Correct Answer: 1,3,4,5

Rationale 1: Actions to improve the immune system for the older patient include maintaining a healthy weight.
Reference: Page 659

Rationale 2: There is no reason for the older patient to restrict the intake of dairy products. These products do not adversely affect the immune system.
Reference: Page 659

Rationale 3: Actions to improve the immune system for the older patient include taking a daily multivitamin/mineral supplement.
Reference: Page 659

Rationale 4: Actions to improve the immune system for the older patient include reporting increased infections to the healthcare practitioner.
Reference: Page 659

Rationale 5: Actions to improve the immune system for the older patient include engaging in regular moderate exercise 30 minutes a day, 5 days a week.
Reference: Page 659

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Identify nursing interventions that can be effective in improving immune status in the older person.

Question 19

Type: MCMA

An older patient with rheumatoid arthritis rates current pain as being a 3 on a scale from 1 to 10. Which nonpharmacological interventions can the nurse provide to help this patient?

Standard Text: Select all that apply.

1. Massage

2. Warm soaks

3. Diversion activities

4. Relaxation techniques

5. Immobilization of painful areas

Correct Answer: 1,2,3,4

Rationale 1: Nonpharmacological comfort measures include massage.
Reference: Page 662

Rationale 2: Nonpharmacological comfort measures include warm soaks.
Reference: Page 662

Rationale 3: Nonpharmacological comfort measures include diversion activities.
Reference: Page 662

Rationale 4: Nonpharmacological comfort measures include relaxation techniques.
Reference: Page 662

Rationale 5: Nonpharmacological comfort measures include aids for mobility. Painful areas should not be immobilized.
Reference: Page 662

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Relate the care of the patient with a rheumatoid disorder to the pathology involved.

Question 20

Type: MCSA

The nurse is planning care for an older patient recently diagnosed with HIV who wants to remain sexually active. Which would be a priority nursing diagnosis for this patient?

1. Self-care deficit related to depression

2. Social isolation related to fear of AIDS

3. Risk for infection related to immunodeficiency

4. Knowledge deficit related to preventing transmission of HIV

Correct Answer: 4

Rationale 1: There is no evidence that the patient has a self-care deficit or is experiencing depression.
Reference: Page 664

Rationale 2: There is no evidence that the patient is experiencing social isolation or has a fear of AIDS.
Reference: Page 664

Rationale 3: The patient does have a risk for infection because of immunodeficiency but this does not address the patients desire to remain sexually active.
Reference: Page 664

Rationale 4: Knowledge deficit related to preventing transmission of HIV would be the priority diagnosis for this patient due to the statement of wanting to remain sexually active.
Reference: Page 664

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Outline the unique characteristics associated with HIV infection in the older person.

Question 21

Type: MCSA

The staff development instructor is planning an inservice for nursing staff on the theories of aging. What should the instructor include about immune dysregulation?

1. Immune cells attack the normal body tissues.

2. The ability to differentiate between invaders and normal tissues diminishes with age.

3. The immune system is not able to defend the body from foreign invaders with age.

4. Changes in the immune system disrupt the regulation of immune process components.

Correct Answer: 4

Rationale 1: Immune dysregulation is caused by changes in the immune system which disrupt the regulation between the components of the immune process. This does not mean that immune cells attack normal body tissues.
Reference: Page 651

Rationale 2: Immune dysregulation is caused by changes in the immune system which disrupt the regulation between the components of the immune process. This does not mean that the ability to differentiate between invaders and normal tissues diminishes.
Reference: Page 651

Rationale 3: Immune dysregulation is caused by changes in the immune system which disrupt the regulation between the components of the immune process. This does not mean that the immune system is not able to defend the body from foreign invaders.
Reference: Page 651

Rationale 4: Immune dysregulation is caused by changes in the immune system which disrupt the regulation between the components of the immune process.
Reference: Page 651

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Identify factors that affect proper immune system function.

Question 22

Type: MCSA

An older patient experiences an allergic reaction to latex. Which should the nurse explain to the patient about this allergy?

1. You probably never realized that you had a latex allergy.

2. Allergic reactions happen more often when you are sick.

3. Allergic reactions can take up to 2 weeks with a latex allergy.

4. You were receiving medication that caused the reaction to latex.

Correct Answer: 3

Rationale 1: Type IV hypersensitivity is also called delayed hypersensitivity. The normal reaction occurs within 1 to 14 days after exposure but it is slower in older adults. A latex allergy is type IV hypersensitivity.
Reference: Page 663

Rationale 2: Type IV hypersensitivity is also called delayed hypersensitivity. The normal reaction occurs within 1 to 14 days after exposure but it is slower in older adults. A latex allergy is type IV hypersensitivity. This type of reaction does not occur more often when a person is sick.
Reference: Page 663

Rationale 3: Type IV hypersensitivity is also called delayed hypersensitivity. The normal reaction occurs within 1 to 14 days after exposure but it is slower in older adults. A latex allergy is type IV hypersensitivity.
Reference: Page 663

Rationale 4: Type IV hypersensitivity is also called delayed hypersensitivity. The normal reaction occurs within 1 to 14 days after exposure but it is slower in older adults. A latex allergy is type IV hypersensitivity. A latex allergy does not need medication to potentiate the allergy.
Reference: Page 663

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Distinguish the similarities, differences, and interactions among the humoral immune response and the cellular immune response.

Question 23

Type: MCSA

An older patient is frustrated because of two hospitalizations within a year for a lung infection. Which response by the nurse is most appropriate?

1. With aging the immune system just quits working.

2. With aging there in an overall increase in the speed and strength of the immune response.

3. With aging there is an increase in the number of B cells in the circulation which hinders the immune response.

4. With aging there is a decrease in the speed and strength of the immune system, which increases the risk for developing an infection.

Correct Answer: 4

Rationale 1: The immune system does not quit working totally.
Reference: Page 654

Rationale 2: As a person grows older, there is an overall decrease in the speed and strength of the immune response. This is called immunosenescence.
Reference: Page 654

Rationale 3: With aging there is a decrease in the number of B cells in circulation.
Reference: Page 654

Rationale 4: As a person grows older, there is an overall decrease in the speed and strength of the immune response. This is called immunosenescence.
Reference: Page 654

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Identify factors that affect proper immune system function.

Question 24

Type: MCSA

The nurse planning to implement a tai chi program at a senior center is meeting resistance by program attendees. How should the nurse respond to the resistance?

1. Tai chi is the only type of exercise that will benefit the immune response in older people.

2. There is no research to show that tai chi has benefits, but just getting out and moving helps.

3. Studies have shown that tai chi will help reduce the levels of IgG and IgM in the circulatory system.

4. Studies have been shown that tai chi is beneficial to cardiorespiratory function, mental control, flexibility, and the immune system.

Correct Answer: 4

Rationale 1: Studies have shown that exercise, whether aerobic or resistance can prevent or slow the age-related decline in the immune response.
Reference: Page 658

Rationale 2: Studies have shown that tai chi increases the levels of IgG and IgM in the circulatory system and is beneficial to cardiorespiratory function, mental control, flexibility, balance control, muscle strength, and the immune system.
Reference: Page 658

Rationale 3: Studies have shown that tai chi increases the levels of IgG and IgM in the circulatory system.
Reference: Page 658

Rationale 4: Studies have shown that tai chi is beneficial to cardiorespiratory function, mental control, flexibility, balance control, muscle strength, and the immune system.
Reference: Page 658

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Identify factors that affect proper immune system function.

Question 25

Type: MCMA

The nurse is planning interventions to help improve the immune function of an older patient. What should be included in this patients plan of care?

Standard Text: Select all that apply.

1. Teach to avoid alcohol.

2. Educate on the effects of stress.

3. Encourage to take daily vitamin supplements.

4. Remind to obtain a yearly influenza vaccination.

5. Encourage to utilize positive coping strategies to stress.

Correct Answer: 2,3,4,5

Rationale 1: Alcohol intake has not been identified as hindering immune function in an older patient.
Reference: Page 669

Rationale 2: An intervention to improve the immune function of an older patient is to educate the patient on the effects of stress.
Reference: Page 669

Rationale 3: An intervention to improve the immune function of an older patient is to encourage the patient to take daily vitamin supplements.
Reference: Page 669

Rationale 4: An intervention to improve the immune function of an older patient is to remind the patient to obtain a yearly influenza vaccination.
Reference: Page 669

Rationale 5: An intervention to improve the immune function of an older patient is to encourage the patient to utilize positive coping strategies for stress.
Reference: Page 669

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Identify factors that affect proper immune system function.

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