Deck 14: Hypersensitivity and Autoimmune Disorders

Question 1

The nurse is providing education to a client prescribed with intranasal cromolyn. Which statement will the nurse include in the client teaching about this medication?

A) "This medication increases your antibodies to the offending allergens."
B) "It's best to use this medication when your symptoms are not tolerable."
C) "Do not use this medication for more than a week at a time."
D) "This medication stabilizes your cells in an effort to fight the offending allergens."

Answer 1

"This medication stabilizes your cells in an effort to fight the offending allergens."

Question 2

The nurse is caring for a client who experienced an immune response resulting from exposure to a foreign material. Which blood components or pathophysiological processes represent foreign materials? Select all that apply.

A) Autologous stem cells
B) One unit of packed red blood cells (PRBCs)
C) Thromboembolism
D) Normal saline solution
E) Renal calculus

Answer 2

One unit of packed red blood cells (PRBCs)
Normal saline solution

Question 3

The nurse is educating a client about the functions of the immune system. Which statements will the nurse include in the teaching materials? Select all that apply.

A) "The immune system's primary function is autoimmunity."
B) "The immune system is responsible for hypersensitivity reactions."
C) "The immune system protects against invading microorganisms."
D) "The immune system prevents cancer cell proliferation."
E) "The immune system mediates the healing of damaged tissue."

Answer 3

"The immune system protects against invading microorganisms."
"The immune system prevents cancer cell proliferation."
"The immune system mediates the healing of damaged tissue."

Question 4

The nurse is caring for a newborn baby. What is the nurse's understanding of this client's immunity?

A) The infant is not protected against antigens during the first month of life.
B) Maternal IgA is transferred to breastfed infants.
C) Breastfeeding does not provide any additional immunity to the baby.
D) An infant only receives immunity during gestation.

Question 5

The nurse is caring for a client who is five months pregnant and HIV positive. What is the nurse's understanding of the neonate's HIV status?

A) The neonate will be HIV positive.
B) The neonate will initially test positive for antibodies.
C) The neonate's risk for contracting HIV is unaffected by the mother's HIV positivity.
D) The neonate may or may not be infected with HIV.

Question 6

The nurse is educating an older adult client about age-related changes in immunity. Which statements will the nurse include in the education? Select all that apply.

A) "There is a higher incidence of cancer with advanced age."
B) "Abscesses, scar formation, and persistent inflammation are more common with advanced age."
C) "Older adults are more susceptible to infection."
D) "Older adults have decreased immunity due to an increase in tissue integrity."
E) "Both types of immune responses are affected with advanced age."

Question 7

The nurse is caring for a client with a diagnosis of lymphedema. Which body component does the nurse recognize as making up the peripheral lymphoid organs? Select all that apply.

A) Bone marrow
B) Tonsils
C) Lymph nodes
D) Thymus
E) Spleen

Question 8

The nurse is caring for a client with an allergic reaction. What is the nurse's understanding of this type of hypersensitivity reaction?

A) It is a Type I reaction, an IgE mediated disorder.
B) It is a Type II reaction, an antibody-mediated disorder.
C) It is a type III reaction, a complement-mediated disorder.
D) It is a type IV reaction, a T-cell mediated disorder.

Question 9

The nurse is caring for a client with Graves disease. What concept related to the client's condition does the nurse recognize as true?

A) Autoantibodies against TSH stimulates thyroxine production.
B) It occurs in hemolytic disease of the newborn due to ABO or Rh incompatibility.
C) Antibodies to acetylcholine receptors cause decreased neuromuscular function.
D) It is characterized by the vascular rejection of organ transplantation.

Question 10

The nurse is caring for a client with serum sickness. What does the nurse understand to be a potential cause of this client's condition? Select all that apply.

A) Drugs
B) Pollen
C) Phagocytes
D) Foods
E) Insect venom

Question 11

The nurse is caring for an older adult client with active tuberculosis (TB) who has a negative TB skin test. The nurse understands that this phenomenon is due to:

A) prior exposure to TB producing antibody immunity.
B) hyperactivity of the immune system occurring with active TB (anergy).
C) a diminished immune response due to changes in immunity occurring with age.
D) decreased immunity associated with treatment with immune-suppressive agents.

Question 12

The nurse is administering a tuberculin skin test for a client. What is the nurse's understanding of the hypersensitivity response associated with this test? Select all that apply.

A) The test causes a release of lymphokines, which attract macrophages.
B) Macrophages release lysozymes, resulting in local tissue damage.
C) The antigen-presenting cell encounters a cytotoxic T-cell.
D) Antigens invade the body and bind to antibodies in circulation.
E) Antigen-antibody complexes activate complement.

Question 13

The nurse is caring for a client with serum sickness. Which interventions will the nurse anticipate will be included in the client's collaborative plan of care? Select all that apply.

A) Aspirin for joint pain
B) Levothyroxine treatment for hypothyroidism
C) Diphenhydramine for pruritus
D) Systemic corticosteroid therapy for severe reactions
E) Prochlorperazine for nausea

Question 14

The nurse acts as a preceptor to a novice nurse, who is caring for a client with a penicillin allergy. Which statement by the novice nurse requires further follow up by the nurse preceptor?

A) "The client has a type I hypersensitivity disorder."
B) "The client likely has certain food allergies."
C) "I will administer the prescribed doxycycline."
D) "I will administer the prescribed amoxicillin."

Question 15

The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). What does the nurse understand about the etiology and pathogenesis of this condition? Select all that apply.

A) Clinical manifestations are mediated by antibody formation and the creation of immune complexes (IC).
B) Lupus is more common in men than in women.
C) Lupus can be drug-induced by the body's overreaction to medications such as isoniazid, hydralazine, and procainamide.
D) It is most common in individuals of Hispanic and Latino descent.
E) The rate ICs are cleared in the liver and spleen are believed to be impaired in SLE.

Question 16

The nurse is caring for a client with a suspected autoimmune disorder. What concept related to the client's condition does the nurse recognize is true? Select all that apply.

A) It is necessary to determine that immunologic findings do not have another cause.
B) Diagnosis is currently based on serologic testing and clinical findings.
C) Each method of serologic testing involves either concentrating or diluting the client's serum.
D) Genetic testing is considered the most reliable way to diagnose autoimmune disorders.
E) Serologic testing reveals autoantibodies directed against cellular components.

Question 17

The nurse is caring for a client who began experiencing symptoms of systemic lupus erythematosus (SLE) about one year ago. What does the nurse understand to be potential causes of this condition? Select all that apply.

A) Heredity
B) Trigger microorganisms
C) Environment
D) Substance abuse
E) Self-antigen from a tissue in the body

Question 18

The nurse is educating a client with an autoimmune disorder about immune tolerance. Which statement should the nurse include in the teaching?

A) "Humoral tolerance refers to the ability to differentiate foreign antigens from self-antigens."
B) "Self-tolerance refers to the elimination of self-reactive T-cells and B-cells in the thymus."
C) "Central tolerance refers to the loss of self-tolerance that occurs as a result of the development of autoantibodies."
D) "Peripheral tolerance occurs when certain immune cells are not eliminated in the central lymphoid organs."

Question 19

The nurse is performing a skin assessment on a client diagnosed with systemic lupus erythematosus (SLE). Which assessment findings does the nurse anticipate? Select all that apply.

A) Paronychia
B) Facial butterfly rash
C) Discoid lesions
D) Alopecia
E) Contact dermatitis

Question 20

The nurse is providing education for a client diagnosed with systemic lupus erythematosus (SLE). Which statement by the client indicates an understanding of the teaching?

A) "I can anticipate my care to be managed solely by my rheumatologist."
B) "I can expect to no longer need treatment after I finish my prescribed medications."
C) "My medications are the mainstay of my treatment."
D) "I will use high sun protection factor (SPF) sunscreen when I spend time outdoors."