Deck 18: Assessment of Immune Function

Question 1

The nurse correlates the function of the thymus gland to which outcome?
1)White blood cell development
2)T-cell development
3)Cytokine production
4)B-cell production

Answer 1

2

Question 2

The nurse educates a patient on first-line anatomic barriers to infection. Which patient statement indicates to the nurse the need for further teaching?
1)"Vomiting is an anatomic barrier to infection."
2)"Coughing is an anatomic barrier to infection."
3)"My saliva is an anatomic barrier to infection."
4)"My skin acts as an anatomic barrier to infection."

Answer 2

3

Question 3

Which laboratory value requires an intervention by the nurse for the patient scheduled for a positron emission tomography (PET) scan?
1)White blood cell (WBC) count 12.5 10³/mm³
2)Platelet count 450 mm³
3)Serum sodium 148 mEq/L
4)Serum glucose 250 mg/dL

Answer 3

4

Question 4

The nurse monitors for which laboratory result in the patient with a history of chronic inflammation?
1)Decreased white blood cell count
2)Elevated red blood cell count
3)Elevated erythrocyte sedimentation rate (ESR)
4)Decreased platelet count

Question 5

The nurse provides education to an older adult patient regarding age-related immune system changes. Which patient statement indicates the need for further teaching?
1)"I am at an increased risk for cancer because of my age."
2)"I may experience a decreased production of autoantibodies as I age."
3)"If I am exposed to a virus, my body's immune response is less efficient."
4)"If my body produces malignant cells, it likely does not destroy them as quickly now."

Question 6

A nurse is caring for a patient with who is experiencing leukocytosis. When providing care to this patient, which action by the nurse is the most appropriate?
1)Assessing for the source of infection
2)Assessing for bleeding and bruising
3)Placing the patient in reverse isolation precautions
4)Instructing the patient on the use of an electric razor and soft toothbrush

Question 7

The nurse recognizes which type of immunity as an example of passive immunity?
1)Immunity acquired based on exposure to an antigen
2)Immunity acquired to a newborn through the placenta
3)Immunity acquired from an immunization
4)Immunity acquired from an infection

Question 8

The nurse correlates an increased risk of infection in a patient receiving radiation therapy for lung cancer based on which of the following factors?
1)Damage to second line of defense
2)Damage to first line of defense
3)Elevated white blood cell production
4)Decreased phagocytic action

Question 9

The nurse is teaching a new mother the immune benefits of breastfeeding her newborn. The nurse bases this teaching on the understanding that which immunoglobulin (Ig) is passed from mother to newborn through breast milk?
1)IgA
2)IgD
3)IgE
4)IgG

Question 10

Which question does the nurse need to ask during a health history with an adolescent patient, accompanied by a parent, to determine immune status?
1)"Is your child sexually active?"
2)"Does your child get annual checkups?"
3)"Does your child smoke tobacco products?"
4)"Are your child's immunizations up-to-date?"

Question 11

Which of the following statements from the patient related to a scheduled bone marrow aspiration indicates patient understanding of the procedure?
1)"I am glad this is not painful like a bone marrow biopsy."
2)"I need to contact my provider if I have a lot of bleeding after I go home."
3)"I will have to monitor for signs of infection after the procedure."
4)"I am glad that I will be able to receive pain medications as needed."

Question 12

The nurse correlates which type of immunoglobulin (Ig) as playing a role in an allergic reaction?
1)IgA
2)IgD
3)IgE
4)IgM

Question 13

Which clinical manifestation noted during the patient's assessment indicates the need to notify the healthcare provider?
1)Coughing and sneezing
2)Earwax noted in the left canal
3)Tear production in both eyes
4)Swelling and redness noted to ankle

Question 14

The nurse is teaching a group of patients about first-line defense against infection. Which patient statement indicates the need for further education?
1)"The skin is a first-line defense against infection."
2)"A sneeze is a mechanical first-line defense against infection."
3)"My saliva is a biochemical first-line defense against infection."
4)"A cut with pus is a mechanical first-line defense against infection."

Question 15

The nurse is conducting a health history for a patient. In assessing immune function, which question is best to ask related to risk factors in the patient's social history?
1)"Do you smoke cigarettes?"
2)"Are your immunizations current and up-to-date?"
3)"What type of reaction do you have with an allergy flair?"
4)"Did you have your spleen removed after your car accident?"

Question 16

The nurse recognizes that which immunoglobulin (Ig) is a mediator in allergic responses?
1)IgA
2)IgD
3)IgE
4)IgG

Question 17

The nurse assesses a patient with a surgical wound infection. Which clinical manifestation leads the nurse to conclude that the patient is experiencing a system response to inflammation?
1)Pain
2)Fever
3)Edema
4)Drainage

Question 18

The nurse correlates the increased risk of autoimmune disorders in the older adult to which age-related change of the immune system?
1)Increased B-cell production
2)Increased autoantibodies production
3)Increased T-cell production
4)Increased phagocytic capacity

Question 19

Which type of leukocyte releases heparin as part of the inflammatory response?
1)Basophil
2)Eosinophil
3)Monocyte
4)Neutrophil

Question 20

In reviewing the laboratory results for a patient admitted with hepatic disease, the nurse correlates which results with an increased risk of infection?
1)White blood cell (WBC) count 5.0 10³/mm³
2)Neutrophils 30%
3)Eosinophils 2%
4)Monocytes 8%

Question 21

The nurse is assessing a patient's immune system. Which findings increase the patient's risk for infection as a result of alterations in mechanical barriers? Select all that apply.
1)Dysphagia
2)Dry mouth
3)Nonintact skin
4)Urinary retention
5)Clogged tear duct

Question 22

A nurse working in the emergency department (ED) is providing care for a group of patients. Which patient demonstrates a decline in immune response that typically occurs with the aging process?
1)An 88-year-old with pneumonia who has a temperature of 99.5°F.
2)A 56-year-old who has an 8-mm induration at the site of a purified protein derivative (PPD) skin test 72 hours earlier.
3)A 58-year-old who reports redness and itching as a result of a rash from contact with poison ivy.
4)A 70-year-old who has swelling and redness at the incision from an open appendectomy.

Question 23

The nurse recognizes which nutritional deficiency as often impacting an older adult patient's ability to mount an immune response?
1)Proteins
2)Calcium
3)Potassium
4)Fats

Question 24

In providing care to a patient with an acute inflammatory response, the nurse correlates the following physiological responses as part of this process. Place the physiological responses in order from earliest to latest.
1) Cellular injury
2) Increased blood flow to area
3) Phagocytes and antibodies to site
4) Vasodilation
5) Pathogenic invasion 6. Inflammatory reponse

Question 25

Which locations does the nurse include when discussing the storage and production of lymphocytes during an education session for novice nurses? Select all that apply.
1)Liver
2)Spleen
3)Thymus
4)Lymph nodes
5)Bone marrow

Question 26

The nurse educates a patient who is malnourished to increase foods that are considered complete protein sources to decrease the risk for infection. Which food choices indicate to the nurse the need for further teaching? Select all that apply.
1)Corn
2)Milk
3)Fish
4)Eggs
5)Chicken

Question 27

The nurse is conducting a physical assessment for a patient with a compromised immune system. Which actions by the nurse are appropriate? Select all that apply.
1)Assessing general appearance
2)Evaluating extraocular eye movement (EOM)
3)Checking joint range of motion (ROM), including that of the spine
4)Inspecting the mucous membranes of the nose and mouth for color and condition
5)Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness

Question 28

The nurse correlates which factors to immunosenescence? Select all that apply.
1)Increased risk of infection
2)Increased risk of hearing loss
3)Increased risk of cancer
4)Increased risk of autoimmune disorders
5)Increased hypersensitivity reactions

Question 29

The nurse is assessing a patient's immune system. Which findings increase the patient's risk for infection as a result of alterations in biochemical barriers? Select all that apply.
1)Dysphagia
2)Dry mouth
3)Nonintact skin
4)Urinary retention
5)Clogged tear duct

Question 30

In providing care to patients with compromised immune function, it is important that the nurse understand types of immunity. Which of the following leads to acquired (adaptive) immunity? Select all that apply.
1)Biochemical barriers
2)Vaccinations
3)Infection
4)Mechanical barriers
5)Transfer of maternal antibodies