Question 1

A 68-year-old patient tells the nurse she does not understand why she has had more colds over the last several years. The nurse considers which component of normal aging before replying?

Accepted Answer

As individuals age, there is a natural decline in the number and function of T cells, which are critical for fighting off infections such as colds. This can lead to a weakened immune response and an increased susceptibility to infections. The other options (B, C, D) are not directly related to the age-related decline in immune function that can contribute to more frequent illnesses in older adults.

Question 2

The nurse is assessing a patient who appears fatigued and pale and says that he has lost 15 pounds over the last month. It is most important for the nurse to conduct additional assessment for which condition?

Accepted Answer

The combination of unintentional weight loss, fatigue, and pallor may indicate a malignancy or other serious illness and warrants further assessment. While depression or an oral cavity infection may cause some of these symptoms, they alone would not typically cause significant weight loss over a short period of time. Respiratory infection resulting in sensory losses is not a likely cause of the symptoms mentioned.

Question 3

A patient is admitted with a large, inflamed leg wound. The nurse explains that the inflammatory response is initiated by chemicals released by which white blood cell type?

Accepted Answer

Basophils release histamine and other mediators that initiate the inflammatory response, leading to increased blood flow and vessel permeability at the site of injury or infection.

Question 4

A unit secretary is the only staff member of the emergency department who does not contract a viral upper respiratory illness during a recent outbreak. How would the nurse explain this phenomenon?

Accepted Answer

The secretary most likely had been exposed to the virus before and developed secondary immunity, which allowed for protection against future infections with the same virus. This is known as acquired immunity. Immune tolerance (B) refers to the inability of the immune system to recognize and respond to certain antigens. The secretary's immune system being unable to differentiate self from non-self (C) would result in autoimmune disorders, not protection against viral illnesses. Overproduction of plasma cells (D) generally occurs in response to antigens, such as during an infection, but does not necessarily mean the person will be protected from future infection.

Question 5

A patient is diagnosed with a viral infection. The nurse understands that which chemical will act to prevent the spread of the virus to other cells?

Accepted Answer

Interferon is a chemical produced by cells in response to viral infections. It functions to prevent the spread of the virus to other cells by inducing nearby cells to produce antiviral proteins. Interleukin, tissue factor, and tumor necrosis factor are immune system chemicals that function in other ways, such as signaling inflammation or promoting cell death.

Question 6

A patient is demonstrating signs of a delayed immunological response to a virus. Which component of the immune system is responsible for beginning this response?

Accepted Answer

T cells are responsible for beginning the delayed immunological response. They are activated by antigens presented by antigen-presenting cells and then initiate a cascade of immune responses.

Question 7

The parent of a young patient asks the nurse why the child should receive the measles-mumps-rubella vaccination. What is the nurse's best response?

Accepted Answer

The nurse should inform the parent that receiving the vaccination will cause the child to develop active acquired immunity, which will protect against the development of these illnesses. This is the most accurate and evidenced-based response to the parent's question. Option A is not entirely true and may lead to confusion about the need for vaccination. Option B is not recommended as delaying vaccines can put the child at risk of developing these illnesses. Option D is not a recommended response as the nurse should encourage vaccination to protect against preventable diseases.

Question 8

A patient is admitted with liver cirrhosis. The nurse realizes that this patient's immunity might be affected for which reason?

Accepted Answer

The liver plays an important role in producing complement, which is important in both inflammatory and immune responses. Liver cirrhosis can affect the function of the liver and, therefore, its ability to produce complement, which can weaken the patient's immune system. Interferon is produced by cells other than the liver and does not depend on liver function. White blood cells are stored in lymph nodes, spleen, and bone marrow, not in the liver. Red blood cells are primarily produced in the bone marrow.

Question 9

A patient says, "There are so many kinds of bacteria. How does my body know which ones to kill and how to kill them?" What would be the nurse's most accurate response?

Accepted Answer

The answer of A patient says, "There are so many...

Question 10

The nurse is having difficulty palpating a patient's inguinal lymph nodes. How does the nurse interpret this finding?

Accepted Answer

If the nurse is having difficulty palpating the inguinal lymph nodes, it means that they are not enlarged or tender, which is a good finding. This suggests that lymph is draining appropriately without evidence of infection or inflammation.

Question 11

A patient tells the nurse that she washes her hands many times throughout the day because she wants to kill all the germs before she provides care to her small children. What is the nurse's best response to this patient?

Accepted Answer

Bacteria are always present on the skin, and too much hand washing could lead to skin breakdown. The nurse should educate the patient that while hand washing is important, excessive hand washing can lead to skin damage and it's impossible to completely eliminate all bacteria on the skin. Encouraging the patient to use lotion or ointment on areas of skin breakdown would also be helpful. Choices A and D are incorrect as they are not accurate statements and could potentially reinforce obsessive behavior. Choice B is also incorrect as it suggests the use of antibiotics, which should not be used unless prescribed by a healthcare provider.

Question 12

A patient tells the nurse that he is 65 years old and has not had a cold or any other type of infection for at least 30 years. Which assumption can the nurse make about this patient's immune system?

Accepted Answer

The fact that the patient has not had a cold or infection for 30 years suggests that the immune system is functioning well, which would require intact and functioning MHC receptors. The other options are not necessarily related to the patient's immune system based on the information given.

Question 13

The mother of a premature newborn asks the nurse why she needs to wear a protective gown, gloves, and mask when holding her baby. What is the nurse's best response?

Accepted Answer

Premature babies have underdeveloped immune systems, making them more susceptible to infections. Wearing protective gear can prevent the transmission of bacteria, viruses, or other microorganisms that could harm the baby.

Question 14

A patient is admitted with an autoimmune disorder. The nurse plans care for this patient based on which characteristics of autoimmune disorders?

Accepted Answer

Autoimmune disorders occur when the body's immune system mistakenly attacks its own tissues and cells, leading to damage and dysfunction. The body still recognizes non-self antigens (such as bacteria and viruses) and produces white blood cells to combat infections, but the immune system also attacks healthy tissues. There is no evidence that autoimmune disorders are caused by overproduction of histamine.

Question 15

While reviewing a patient's laboratory values, the nurse notes that the complement 3b level is below normal limits. The nurse would interpret this finding as increasing the risk of which patient response?

Accepted Answer

Complement 3b is part of the complement system, which is responsible for recognizing and eliminating foreign cells and antigens. A low level of complement 3b indicates that the body may not be able to recognize all offending cells or antigens for elimination, increasing the risk of infections and immune disorders.

Question 16

The nurse is instructing a female patient who is 6 weeks pregnant. Which information should the nurse include to best ensure the development of an intact immune system in the baby?

Accepted Answer

Eliminating exposure to known toxins can help ensure the development of an intact immune system in the baby. Exposure to toxins during pregnancy can have negative effects on the immune system development in the baby. Engaging in physical activity, limiting alcohol consumption, and reducing smoking can have their own benefits during pregnancy, but they do not have as direct of an impact on the immune system development of the baby.

Question 17

While studying the antibody-antigen response, the nurse understands that an antibody can bind to different types of antigens to protect the body from illness and disease. How would the nurse describe the body's ability to conform to the different antigens?

Accepted Answer

Humoral immunity involves the production of antibodies by B cells. Antibodies can bind to various antigens, neutralizing them or marking them for destruction by other immune cells, thus protecting the body from illness and disease.

Question 18

The nurse is providing care for a patient who has a respiratory infection. Because the infection is in the lung, the nurse expects which immunoglobulin level to be most elevated?

Accepted Answer

Immunoglobulin A (IgA) is primarily found in mucous membranes, including the respiratory tract. Therefore, it is the immunoglobulin that would be most elevated in response to a respiratory infection. IgD is found in trace amounts and its function is not well understood. IgE is often associated with allergies and parasitic infections. IgM is the first immunoglobulin produced in response to an infection, but its levels decrease rapidly and are not sustained during a chronic infection.

Question 19

A patient tells the nurse that this illness is "much less" than the last one. What is one way for the nurse to interpret this statement?

Accepted Answer

The patient's statement suggests that they have had the illness before and that their current symptoms are less severe than the previous time. This indicates that their immune system has already encountered the pathogen before and has mounted a secondary immune response, resulting in less severe symptoms. Option A, natural immunity, would suggest that the patient has never been exposed to the pathogen before. Option B, primary immune response, would suggest a first-time exposure to the pathogen which is not consistent with the patient's statement. Option D, inflammatory response, is a nonspecific response to injury or infection, and does not directly relate to the patient's statement about their illness being less severe than a previous one.

Question 20

A patient tells the nurse that he's happy that his wife did not "catch" the same cold from which he has recently recovered. The nurse realizes that what most likely occurred in his wife?

Accepted Answer

The fact that the patient's wife did not "catch" the same cold as the patient suggests that she may have been exposed to the virus before and developed T-helper 2 memory cells for that specific virus, which would provide protection against subsequent infections. The other options do not explain why the patient's wife did not contract the same cold.

Quiz 52: Nursing Management of the Patient With Immunological and Inflammatory Disorders