Concept 20: Immunity My Nursing Test Banks

Concept 20: Immunity

Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patients discharge planning?

a.

The mechanisms of the inflammatory response

b.

Basic infection control techniques

c.

The importance of wearing a face mask in public

d.

Limiting contact with the general population

ANS: B

The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

REF: 207-208 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

2. An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the childs growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for

a.

primary immunodeficiency.

b.

secondary immunodeficiency.

c.

cancer.

d.

autoimmunity.

ANS: A

Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

REF: 205

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation if

a.

his immune system is functioning properly.

b.

he is properly vaccinated.

c.

he has an infection.

d.

the suppressor T-cells in his body are activated.

ANS: A

Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the bodys response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.

REF: 213

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she states which of the following?

a.

My body will treat the new kidney like my original kidney.

b.

I will have to make sure that I avoid being around people.

c.

The medications that I take will help prevent my body from attacking my new kidney.

d.

My body will only have a problem with my new kidney if the donor is not directly related to me.

ANS: C

Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they dont have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.

REF: 206 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

5. The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patients respirations are 26 breaths/min with pulse 112 beats/min and weak. The nurse suspects that the patient is experiencing a(n)

a.

suppressed immune response.

b.

hyperimmune response.

c.

allergic reaction.

d.

anaphylactic reaction.

ANS: D

The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response.

REF: 210

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

6. The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse explains to the patient that the goal of medication treatments for RA is to

a.

eradicate the disease.

b.

enhance immune response.

c.

control inflammation.

d.

manage pain.

ANS: C

Medications for RA are intended to control the inflammation that results from the bodys hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

REF: 205|210|213 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The parents of a newborn question the nurse about the need for vaccinations: Why does our baby need all those shots? Hes so small, and they have to cause him pain. The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.)

a.

Are only required for infants

b.

Are part of primary prevention for system disorders

c.

Prevent the child from getting childhood diseases

d.

Help protect individuals and communities

e.

Are risk free

f.

Are recommended by the Centers for Disease Control and Prevention (CDC)

ANS: B, D, F

Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient wont get the disease, but it decreases the potential to contract the illness. No medication is risk free.

REF: 212 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

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