Deck 19: Inflammation and the Immune Response

Question 1

A client recovering from hepatitis A asks whether he should take the vaccine to avoid contracting the disease again.What does the nurse say?

A) "Yes, because now you are more susceptible to this infection."
B) "Yes, because the hepatitis A virus changes from year to year."
C) "No, your liver and immune system are too impaired at this time."
D) "No, having the infection has done the same thing a vaccination would."

Answer 1

"No, having the infection has done the same thing a vaccination would."

Question 2

The nurse receives a report that a client's laboratory results show a left shift or an increase in circulating band neutrophils.What is the nurse's best action?

A) Keep the client on bedrest.
B) Prepare the client for surgery.
C) Increase the client's oxygen flow rate.
D) Assess the client's vital signs.

Answer 2

Assess the client's vital signs.

Question 3

An older adult client tells the nurse that her granddaughter has chickenpox.The client is afraid to visit because she is afraid of getting shingles from her granddaughter.What is the nurse's best response?

A) "If you already had chickenpox, you cannot get shingles."
B) "If you already had shingles, you cannot get them again."
C) "If you already had chickenpox, you can safely visit your granddaughter."
D) "Shingles is caused by a different virus than the chickenpox virus."

Answer 3

"If you already had chickenpox, you can safely visit your granddaughter."

Question 4

A client reports severe hay fever and allergic rhinitis.Which finding does the nurse expect to see in this client's laboratory results?

A) Band neutrophils outnumber segmented neutrophils.
B) The basophil count is 50/mm³.
C) The eosinophil count is 20%.
D) The white count is 7500/mm³.

Question 5

The nurse is caring for an older postoperative client.Which assessment finding causes the nurse to assess further for a wound infection?

A) Moderate serosanguineous drainage is seen on the dressing.
B) The client is now confused but was not confused previously.
C) The white blood cell differential indicates a right shift.
D) The white blood cell count is 8000/mm³.

Question 6

The nurse is teaching a client with a leg injury and warmth around the injured area.Which statement by the client indicates a good understanding?

A) "The warmth indicates an infection."
B) "The warmth indicates increased blood flow."
C) "Warmth indicates that the tissues are rebuilding."
D) "Warmth results from localized vasoconstriction."

Question 7

Which client is at highest risk of compromised immunity?

A) Client who has just had surgery
B) Client with extreme anxiety
C) Client who is awaiting surgery
D) Client who just delivered a baby

Question 8

The nurse assesses a cut that is 24 hours old and finds that the site is swollen,red,and tender to the touch.Which cell types are responsible for these assessment findings?

A) Erythrocytes and platelets
B) Basophils and eosinophils
C) Plasma cells and B-lymphocytes
D) Natural killer cells

Question 9

The nurse is assessing a client who cannot synthesize suppressor T-cells.For what other condition does the nurse assess the client?

A) Increased seasonal allergies
B) Multiple sclerosis
C) Leukemia
D) Graft-versus-host disease

Question 10

A client who has an extensive burn injury develops inflammation that covers the entire body.What is the nurse's best action?

A) Notify the health care provider immediately.
B) Document the assessment.
C) Take the client's temperature.
D) Ask for an order for antibiotic therapy.

Question 11

A client's white blood cell (WBC)count value is 10,000 cells/mm³.The nurse reviews the differential.Which counts or percentages is the nurse sure to report to the provider?

A) Eosinophils, 200/mm³
B) A left shift in the white count
C) Segmented neutrophils, 6000/mm³
D) Basophils 100/mm³

Question 12

A client had a splenectomy.Which fact is most important to teach the client regarding immune function?

A) "You won't get a fever with infection, so you need to learn to identify other symptoms."
B) "It will no longer be necessary for you to worry about developing allergies."
C) "Avoid people who are ill because it will be harder for you to develop antibodies."
D) "You will need to be assessed yearly for the risk of developing cancer."

Question 13

The nurse is caring for a client who has undergone a kidney transplant.The client asks the nurse what will happen when his body realizes that the kidney is not "his." What is the nurse's best response?

A) "The immune system will try to destroy the kidney if we don't suppress it."
B) "As long as the kidney is a 'match' to your blood type, there will be no problem."
C) "You will develop a fever or other complications from the transplant."
D) "Within a week, your body will 'adjust' to the new organ."

Question 14

A client has a reduction in immune function.What is the nurse's priority action for this client?

A) Determine whether it is temporary or permanent.
B) Take the client's vital signs every 4 hours.
C) Teach family members to receive the flu shot yearly.
D) Wash hands before entering the room.

Question 15

The nurse is assessing a client who has a wound on the left calf.Drainage is coming from the wound.What does the nurse tell the client about this finding?

A) "Exudate or drainage is a natural occurrence with inflammation."
B) "Exudate or drainage means the wound is infected."
C) "Drainage from a wound is never a good sign."
D) "All wounds result in bleeding and pus formation."

Question 16

A client has an injury to the right ankle.On assessment,the nurse notes that it is red and inflamed.The nurse adds interventions to the care plan that address which factor?

A) An injury that is infected
B) Inflammation without infection
C) A secondary infection
D) Dermatitis around the ankle

Question 17

A client enters the emergency department (ED)with an injury to the wrist.In assessment,the nurse notes that the area is red,warm,and edematous.What is the nurse's best action?

A) Apply a heating pad to the area.
B) Inject pain medication directly at the site.
C) Start an IV infusion of a vasoconstrictive drug.
D) Assess circulation and elevate the extremity.

Question 18

The nurse prepares to administer a tetanus toxoid vaccination to a client who has suffered a puncture wound.The client reports that he had a tetanus shot just 1 year ago.What is the nurse's best action?

A) Give the vaccination because strains of tetanus change yearly.
B) Refrain from giving the vaccination if the client is reliable.
C) Give a smaller dose because antibody production slows down with aging.
D) Give the shot because it won't hurt to receive an extra dose of the toxoid.

Question 19

A client has been diagnosed with a deficiency of complement proteins.Which assessment is the item of highest priority for the nurse to perform?

A) Joint stiffness and range of motion
B) Enlarged lymph nodes and night sweats
C) Rhinorrhea and conjunctivitis
D) Lung sounds, cough, and oxygen saturation

Question 20

A client's absolute neutrophil count (ANC)is 550/mm³.What is the nurse's best action?

A) Use Standard Precautions.
B) Place the client on antibiotic therapy.
C) Place client on a low-sodium diet.
D) Administer chemotherapy.

Question 21

When an antibody titer to varicella zoster virus is performed on a nurse,the titer is negative.Which result and action by the nurse's supervisor are most appropriate?

A) The nurse has chickenpox and is contagious. The supervisor sends the nurse home.
B) The nurse has never been infected with varicella zoster virus. The supervisor assigns another nurse to care for clients with chickenpox.
C) The nurse had a subclinical case of herpes at least 5 years ago and is now immune to the disease. The supervisor assigns the nurse to a client with chickenpox.
D) The nurse has never been infected with varicella zoster virus and is susceptible to herpes. The supervisor assigns another nurse to a client with herpes.

Question 22

The nurse is teaching a class about the immune system.The nurse asks the class to list various functions of antibodies.Which class responses does the nurse evaluate as indicating a good understanding?

A) "They release chemicals to cause blood vessels to dilate."
B) "They deactivate toxins that are released in an infection."
C) "They tag bacteria so the macrophages know to eat them up."
D) "They cause the person to have a fever."
E) "They tell cells to make collagen for scar tissue."
F) "They turn on the complement system."

Question 23

The nurse has sustained a needle stick injury and received a dose of hepatitis B immune globulin.Which statement indicates that the nurse understands this intervention?

A) "I don't need to receive the hepatitis B vaccine because I already had the immune globulin."
B) "I will need to receive only two doses of the hepatitis B vaccine because I had one dose of the immune globulin."
C) "I need to start the hepatitis B vaccination series as soon as possible."
D) "I will make an appointment to start the hepatitis B vaccination series in 6 weeks."

Question 24

The nurse is providing discharge teaching for a client following a liver transplant.Which statement by the client indicates that additional teaching is needed?

A) "If I develop an infection, I should stop taking the steroid preparation."
B) "If I have tenderness in my abdomen, I will call the physician."
C) "I should avoid people who are ill or who have an infection."
D) "Cyclosporine (Sandimmune) won't work as well if I change the routine."

Question 25

The nurse is teaching a client who has recently given birth about immunity that has been passed to the newborn.Which statement by the client indicates that additional teaching is needed?

A) "My baby received some antibodies from me before birth, and I will give him more when I breast-feed."
B) "I had the measles, so my baby will be protected against it until he is old enough to receive the MMR vaccine."
C) "I had chickenpox and am immune to it, so my baby will not need to have the chickenpox vaccine."
D) "Only certain antibodies were able to cross the placenta to protect my baby."

Question 26

The nurse reviews the laboratory results of a client and finds that the white blood cell (WBC)count is 1500/mm³.What is the priority action of the nurse?

A) Have the client wear a mask at all times.
B) Obtain a urine sample for culture and sensitivity.
C) Administer two units of fresh-frozen plasma.
D) Institute reverse isolation precautions.

Question 27

The nurse suspects acute graft rejection after a client has undergone a kidney transplant.What assessment findings confirm this diagnosis?

A) Temperature of 100.6° F
B) Blood urea nitrogen (BUN) 56 mg/dL
C) Creatinine 3.2 mg/dL
D) Urine output 20 mL/hr
E) Extreme pain in the lower back
F) Edematous ankles

Question 28

The nurse is caring for a client who is depressed because of acute rejection following a kidney transplant.What is the nurse's best response?

A) "This is what happens when you don't take your transplant medications."
B) "At least you can still have dialysis, unlike people who receive liver transplants."
C) "One acute rejection episode does not mean that you will lose the new kidney."
D) "You can always find another donor and get another kidney transplant."

Question 29

For which clients does the nurse assess for inflammation?

A) Client who reports pain
B) Client diagnosed with an ear infection
C) Client who has sunburn
D) Client taking vitamin C 500 mg daily
E) Client with nausea
F) Client reporting reflux
G) Client with frostbite

Question 30

Which type of immunity does the hepatitis B immune globulin provide for the nurse?

A) Passive
B) Artificial active
C) Natural active
D) Cell-mediated