Chapter 41Assessment of Immunological Function My Nursing Test Banks

Chapter 41Assessment of Immunological Function

MULTIPLE CHOICE

1.The mother of a newborn baby is concerned that the baby will develop illnesses from being around so many people. The nurse should explain that the baby has immunity that is present at birth or:

1.

acquired immunity.

2.

adaptive immunity.

3.

innate immunity.

4.

specific immunity.

ANS: 3

Innate immunity or natural immunity is present at birth. It is nonspecific. Acquired immunity is immunity not present at birth and can also be adaptive or specific.

PTS: 1 DIF: Apply REF: Overview of Immunity

2.The nurse instructs a client to use good handwashing and cover her nose and mouth when sneezing. These efforts will reduce others exposure to molecules that can elicit an immune response or:

1.

antigens.

2.

epitopes.

3.

haptens.

4.

immunogens.

ANS: 4

An immunogen is any molecule that elicits an immune response. An antigen is any molecule that can bind with a specific antibody. An antigen that does not elicit an immune response by itself is called a hapten. An epitope is the reaction portion of an antigen.

PTS: 1 DIF: Apply REF: Antigen

3.The nurse is caring for a client who is experiencing an infection. The nurse knows that the body has specific cells to entrap invading organisms. Which of the following cells is not a phagocytic cell?

1.

Dendritic cells

2.

Eosinophils

3.

Macrophages

4.

Neutrophils

ANS: 2

The function of the eosinophils is to release toxic granules that can kill parasites and other microorganisms. Dendritic cells, macrophages, and neutrophils all have phagocytic properties.

PTS: 1 DIF: Analyze REF: Overview of Immunity

4.The nurse, after reviewing a clients immunization history, realizes that which of the following pathogen toxoids would not be given to an individual to develop an immune response?

1.

Attenuated polio

2.

Diphtheria toxoid

3.

Snake toxin

4.

Tetanus toxoid

ANS: 3

Snake toxin works too quickly for the adaptive immune system to be effective. Horses are immunized with the toxin and produce antibodies against the venom. This venom is stored until needed. The other toxoids would be provided to an individual to develop an immune response.

PTS: 1 DIF: Analyze REF: Mechanisms of Immunization

5.Which of the following test results would not be associated with systemic lupus erythematosus (SLE)?

1.

Decreased level of anti-DNA antibodies

2.

Decreased level of total complement

3.

Increased level of antinuclear antibodies

4.

Increased level of rheumatoid factor

ANS: 1

Increased levels of anti-DNA antibodies are associated with SLE. Decreased levels are associated with other connective tissue disorders. SLE is associated with decreased levels of total complement, increased levels of antinuclear antibodies, and increased levels of rheumatoid factor.

PTS:1DIF:AnalyzeREFiagnostic Tests

6.The nurse is concerned that a client will develop an overwhelming infection because which of the following laboratory values is low?

1.

Hematocrit

2.

Hemoglobin

3.

Eosinophils

4.

Neutropils

ANS: 4

Deficiency in neutrophils or neutropenia can cause an overwhelming bacterial infection. Low levels of hemoglobin and hematocrit affect the ability to supply oxygen to the client. Eosinophils are normally found in the blood in small quantities.

PTS:1DIF:AnalyzeREF:Granulocytes

7.Which of the following interventions would be appropriate for a client recovering from a splenectomy?

1.

Assist with ambulation once per shift.

2.

Medicate for pain.

3.

Utilize strict infection control techniques.

4.

Encourage the client to deep breathe and cough every 8 hours.

ANS: 3

Removal of the spleen often results in life-threatening infections known as overwhelming postsplenectomy infections. The nurse should utilize strict infection control techniques when providing care to this client. Ambulation and medicating for pain would be appropriate for any client recovering from surgery. Deep breathing and coughing should be done more frequently than every 8 hours.

PTS: 1 DIF: Apply REF: Secondary Lymphoid Tissue

8.An elderly client, diagnosed with a wound infection, is not demonstrating the expected signs of inflammation. The nurse realizes this is because the:

1.

client is prescribed medications that block this effect.

2.

client is experiencing age-related changes in immunological function.

3.

infection is localized.

4.

client has been misdiagnosed.

ANS: 2

One age-related change in immunological function is suppression of phagocytic activity which will cause an absence of typical signs and symptoms of infection and inflammation. The client is not demonstrating signs of inflammation because of medications, a localized infection, or misdiagnosis.

PTS:1DIF:Analyze

REF:Table 41-4 Age-Related Changes in Immunological Function

9.A client tells the nurse that he is allergic to Valium because he experienced nausea, vomiting, and dizziness after ingesting. How should the nurse document this information?

1.

Client is allergic to Valium.

2.

Client does not want to be prescribed Valium.

3.

Valium has caused an allergic reaction in this client.

4.

Client experiences nausea, vomiting, and dizziness after ingesting Valium.

ANS: 4

Many clients will say that they have allergies to medications when they are really experiencing side effects. Nausea, vomiting, and dizziness are side effects of this medication and not an allergic response. The nurse should document the clients response to the medication and not identify these responses as an allergy.

PTS: 1 DIF: Apply REF: Allergies

10.The nurse is assessing a client for a history of cancer. To aid in this assessment, the nurse can use which of the following words as a mnemonic?

1.

CAUTION

2.

ACTION

3.

RACE

4.

OLDCART

ANS: 1

The word CAUTION can be used as a mnemonic to assess a client for cancer. ACTION is not used for this assessment. RACE is often used to respond to a fire. OLDCART is often used to assess for pain.

PTS: 1 DIF: Apply REF: Cancer

11.A clients social readjustment rating scale score was 325. The nurse should interpret this result as increasing the clients risk for:

1.

disease.

2.

sleep disturbances.

3.

developing obesity.

4.

inactivity.

ANS: 1

The social readjustment rating scale was developed not only as an indicator of stress but also as an indicator of disease. A score above 300 is considered high, which should indicate to the nurse that the client is at risk for developing disease. This score is not interpreted as increasing the clients risk for sleep disturbances, developing obesity, or for inactivity.

PTS: 1 DIF: Analyze REF: Stress and Social Support

12.The nurse is completing a physical assessment with a client. Which of the following findings could be caused by impaired immune function in the client?

1.

Jugular vein distention

2.

Neck pain

3.

Leg rash

4.

Hip pain

ANS: 3

Of the assessment findings provided, leg rash could be caused by impaired immune function in the client. Jugular vein distention, neck pain, and hip pain would most likely have another cause.

PTS:1DIF:Analyze

REF: Box 41-1 Common Physical Signs Associated with Impaired Immune Function

13.The nurse is reviewing the results of a laboratory test to measure the amount of immunoglobulins in a clients blood. Which of the following should have the highest value?

1.

IgA

2.

IgG

3.

IgM

4.

IgE

ANS: 2

Immunoglobulin G is the most abundant immunoglobulin. Immunoglobulin A is the second most abundant immunoglobulin. Immunoglobulin M causes the formation of natural antibodies. Immunoglobulin E is involved in inflammation and allergic responses.

PTS: 1 DIF: Analyze REF: Table 41-5 Immunoglobulin Functions

MULTIPLE RESPONSE

1.Which of the following would the nurse identify as age-related changes in immunologic function that occur in the older adult? (Select all that apply.)

1.

Accelerated phagocytic immune response

2.

Altered nutrition intake

3.

Failure of immune system to differentiate self from nonself

4.

Increased hematuria

5.

Increased adipose tissue

6.

Maintenance of function of the B lymphocytes

ANS: 2, 3, 4

A variety of changes occur as a person begins to age. These changes make the body more susceptible to infections. The phagocytic immune response is suppressed, and the B lymphocytes are impaired. Adipose tissue and skin elasticity decrease. Nutrition intake is impaired, and frequently the older adult has inadequate protein intake. Within the urinary system, one age-related change is hematuria.

PTS:1DIF:Apply

REF:Table 41-4 Age-Related Changes in Immunological Function

2.The nurse is using a systematic approach to assessing a clients mole. Which of the following is included in this approach? (Select all that apply.)

1.

Asymmetry

2.

Border

3.

Color

4.

Containment

5.

Density

6.

Diameter

ANS: 1, 2, 3, 6

Moles should be screened using the ABCD approach (asymmetry, border, color, and diameter). Containment and density is not a part of this assessment.

PTS: 1 DIF: Apply REF: Integumentary System

3.The nurse is providing medication to a client in order to improve the function of the clients antibodies. Which of the following are considered antibody functions? (Select all that apply.)

1.

Neutralization

2.

Agglutination

3.

Opsonization

4.

Activation of inflammation

5.

Phagocytosis

6.

Activation of complement

ANS: 1, 3, 4, 6

Antibodies work by four basic functions: 1) neutralization, 2) opsonization, 3) activation of inflammation, and 4) activation of complement. Agglutination occurs when an antibody binds to the same epitope on a different antigen. Phagocytosis is the removal of invading organisms by specialized cells.

PTS: 1 DIF: Analyze REF: B Lymphocytes and Antibodies

4.A baby is recovering from a thymectomy. The nurse realizes that this child is at risk for developing which of the following as an adult? (Select all that apply.)

1.

Infections

2.

Increased inflammation

3.

Increase in age-related chronic diseases

4.

Acute otitis media

5.

Gout

6.

Autoimmune responses

ANS: 1, 2, 3, 6

Immunological aging due to thymectomy in infancy can place the individual at increased risk for infections, inflammations, age-related chronic diseases, and autoimmune responses as an adult.

PTS: 1 DIF: Apply REF: Primary Lymphoid Organs

5.A client is demonstrating signs of the inflammatory response. The nurse would assess which of the following in this client? (Select all that apply.)

1.

Increased urine output

2.

Thirst

3.

Edema

4.

Heat

5.

Erythema

6.

Pain

ANS: 3, 4, 5, 6

Inflammation is characterized by localized pain, erythema, heat, and edema. Increased urine output and thirst are not signs of the inflammatory response.

PTS: 1 DIF: Apply REF: Innate Immune Response

Leave a Reply