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

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?

A) There is a decrease in the number and function of T cells.
B) The flu vaccine given to the elderly is not as potent as that given to younger adults.
C) There is a decrease in complement.
D) The B cells respond more rapidly.

Answer 1

There is a decrease in the number and function of T cells.

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?

A) Depression
B) Malignancy
C) Oral cavity infection
D) Respiratory infection resulting in sensory losses

Answer 2

Malignancy

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?

A) Monocytes
B) Eosinophils
C) Basophils
D) Neutrophils

Answer 3

Basophils

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?

A) The secretary had been exposed before and responded with secondary immunity.
B) The secretary has immune tolerance.
C) The secretary's immune system is unable to differentiate self from non-self.
D) The secretary's immune system overproduces plasma cells.

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?

A) Interleukin
B) Tissue factor
C) Tumor necrosis factor
D) Interferon

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?

A) Complement
B) Intact functioning T cells
C) Functioning human leukocyte antigens
D) Intact functioning B cells

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?

A) "Your child will develop immunity to these illnesses even without the vaccination, but at a slower rate."
B) "The child can always receive the vaccination later."
C) "Receiving the vaccination will cause your child to develop active acquired immunity, which will protect against the development of these illnesses."
D) "I know the Centers for Disease Control expects everyone to have this vaccination, but you can always refuse."

Question 8

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

A) Interferon will not function in this patient.
B) White blood cells are stored in the liver.
C) Complement is made in the liver and has a role in inflammatory and immune responses.
D) Red blood cells are made in the liver.

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?

A) "The alkaline environment in the stomach kills any bacteria you might swallow on food or in drinks."
B) "Chemicals on the skin kill many of the bacteria from the environment."
C) "Special white blood cells called toll cells help your body identify disease-causing bacteria."
D) "Your mucous membranes help to filter out and kill bacteria."

Question 10

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

A) The patient has a systemic infection and needs further assessment.
B) The patient will develop lymph edema in the coming years.
C) The inguinal lymph nodes are not functioning properly.
D) 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?

A) "That's a good thing, because hand washing kills all bacteria."
B) "Make sure you use an antibiotic ointment on areas of skin breakdown."
C) "Bacteria are always present on the skin, and too much hand washing could lead to skin breakdown."
D) "When you have young children, there's no such thing as washing your hands too much."

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?

A) The patient's lymph nodes must be engorged with bacteria.
B) The patient must have intact and functioning MHC receptors.
C) The patient has rapidly proliferating white blood cells.
D) The patient's spleen is probably enlarged.

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?

A) "The baby might not have enough immunity because she was born premature."
B) "It is to protect you from exposure to some of the medications the baby is receiving."
C) "You may have hospital germs on your clothing."
D) "We have to protect the baby from the outside environment."

Question 14

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

A) The patient's body does not recognize non-self antigens.
B) The patient's body does not recognize its own tissues.
C) The patient's body does not have enough white blood cells to combat infections.
D) The patient's body overproduces 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?

A) The body will not be able to summon phagocytic cells to areas of infection.
B) The body will not be able to inhibit tumor development caused by chronic inflammation.
C) The body will not recognize all offending cells or antigens for elimination.
D) The body will not recognize the need for platelets to stop blood loss from vessel injury.

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?

A) Engage in light physical activity during the pregnancy.
B) Limit alcohol consumption to one drink per day.
C) Reduce smoking.
D) Eliminate exposure to known toxins.

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?

A) Humoral immunity
B) Natural immunity
C) Cell-mediated immunity
D) Immune tolerance

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?

A) Immunoglobulin D
B) Immunoglobulin E
C) Immunoglobulin A
D) Immunoglobulin M

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?

A) The patient now has natural immunity.
B) The patient has experienced a primary immune response.
C) The patient's immune system has mounted a secondary response to the pathogen.
D) The patient experienced an inflammatory response.

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?

A) Release of cytokines
B) Proliferation of CD 8 cells
C) T-helper 1 stimulation to kill unidentified cells
D) T-helper 2 memory of a previous exposure to the same virus that caused the patient's illness

Question 21

Which assessment findings would the nurse evaluate as indicating inflammation or infection of the superficial lymph nodes? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The nodes are easily palpable.
B) There is edema in the area of the node.
C) The contour of the lymph node is visible.
D) There is cyanosis in the area being assessed.
E) The area over the node is cool to the touch.

Question 22

Which lymph node assessment findings would increase the nurse's concern that a patient has a malignancy? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The node is tender.
B) The node is hard.
C) The node is irregularly shaped.
D) The node is freely movable.
E) The node is easily palpable.

Question 23

While percussing a patient's left lung, the nurse detects a dull percussion note. How would the nurse interpret this finding?

A) The patient has hepatomegaly.
B) The patient might have fluid in the lung, which could indicate an infection.
C) The patient has emphysema.
D) The patient has normal lungs.

Question 24

During an assessment, the nurse notes enlargement and tenderness of the right preauricular lymph nodes. This finding would suggest the need for additional assessment of which areas? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Face
B) Neck
C) Head
D) Breast
E) Upper arm

Question 25

An 85-year-old patient's white blood cell count WBC) is 3,000. How would the nurse interpret this finding? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The count is high, so the patient probably has an infection.
B) The patient's immune system is intact.
C) This WBC count is normal for a patient this age.
D) This count is low and further assessment should be completed.
E) This patient is immunosuppressed.

Question 26

A patient is admitted for an infected leg wound. The nurse notes that the patient's band count on the CBC and differential is elevated. How does the nurse interpret this information?

A) The leg wound was caused by a parasite.
B) The patient could be developing sepsis.
C) The patient is healing.
D) The patient has lymphoma in addition to a leg wound.

Question 27

A patient has dysfunction of immunity associated with Peyer's patches. The nurse interprets this information to indicate a disorder of which areas? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The intestines
B) GALT
C) Spleen
D) Axilla
E) Lungs

Question 28

A patient has a skin infection over the inner aspect of the left thigh. The nurse would anticipate finding enlargement when palpating which lymph nodes? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Inferior inguinal
B) Superior inguinal
C) Preauricular nodes
D) Supraclavicular nodes
E) Axillary nodes

Question 29

The nurse would consider a provisional diagnosis of sepsis as supported by a band count of over ______ % of the total white blood cell count.

Question 30

Review of a patient's medical record reveals the presence of petechiae. How would the nurse interpret this information? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The patient will have a maculopapular rash that extends over at least 30% of the body.
B) The patient has sustained damage to capillary blood vessels.
C) The patient has sustained bruising trauma.
D) The patient will have small purple or red spots.
E) The patient probably has an infection distal to the point where the petechiae begin.