Deck 41: Assessment of Immunological Function

Question 1

An elderly client, diagnosed with a wound infection, is not demonstrating the expected signs of inflammation. The nurse realizes this is because the:

A) client is prescribed medications that block this effect.
B) client is experiencing age-related changes in immunological function.
C) infection is localized.
D) client has been misdiagnosed.

Answer 1

client is experiencing age-related changes in immunological function.

Question 2

Which of the following interventions would be appropriate for a client recovering from a splenectomy?

A) Assist with ambulation once per shift.
B) Medicate for pain.
C) Utilize strict infection control techniques.
D) Encourage the client to deep breathe and cough every 8 hours.

Answer 2

Utilize strict infection control techniques.

Question 3

A client is demonstrating signs of the inflammatory response. The nurse would assess which of the following in this client? (Select all that apply.)

A) Increased urine output
B) Thirst
C) Edema
D) Heat
E) Erythema
F) Pain

Answer 3

Edema
Heat
Erythema
Pain

Question 4

The nurse, after reviewing a client's immunization history, realizes that which of the following pathogen toxoids would not be given to an individual to develop an immune response?

A) Attenuated polio
B) Diphtheria toxoid
C) Snake toxin
D) Tetanus toxoid

Question 5

The nurse is assessing a client for a history of cancer. To aid in this assessment, the nurse can use which of the following words as a mnemonic?

A) CAUTION
B) ACTION
C) RACE
D) OLDCART

Question 6

The nurse is using a systematic approach to assessing a client's mole. Which of the following is included in this approach? (Select all that apply.)

A) Asymmetry
B) Border
C) Color
D) Containment
E) Density
F) Diameter

Question 7

Which of the following would the nurse identify as age-related changes in immunologic function that occur in the older adult? (Select all that apply.)

A) Accelerated phagocytic immune response
B) Altered nutrition intake
C) Failure of immune system to differentiate self from nonself
D) Increased hematuria
E) Increased adipose tissue
F) Maintenance of function of the B lymphocytes

Question 8

The nurse is caring for a client who is experiencing an infection. The nurse knows that the body has specific cells to entrap invading organisms. Which of the following cells is not a phagocytic cell?

A) Dendritic cells
B) Eosinophils
C) Macrophages
D) Neutrophils

Question 9

A baby is recovering from a thymectomy. The nurse realizes that this child is at risk for developing which of the following as an adult? (Select all that apply.)

A) Infections
B) Increased inflammation
C) Increase in age-related chronic diseases
D) Acute otitis media
E) Gout
F) Autoimmune responses

Question 10

The nurse is completing a physical assessment with a client. Which of the following findings could be caused by impaired immune function in the client?

A) Jugular vein distention
B) Neck pain
C) Leg rash
D) Hip pain

Question 11

Which of the following test results would not be associated with systemic lupus erythematosus (SLE)?

A) Decreased level of anti-DNA antibodies
B) Decreased level of total complement
C) Increased level of antinuclear antibodies
D) Increased level of rheumatoid factor

Question 12

A client's social readjustment rating scale score was

A) disease.
B) sleep disturbances.
C) developing obesity.
325) The nurse should interpret this result as increasing the client's risk for:
D) inactivity.

Question 13

The nurse is concerned that a client will develop an overwhelming infection because which of the following laboratory values is low?

A) Hematocrit
B) Hemoglobin
C) Eosinophils
D) Neutropils

Question 14

The nurse instructs a client to use good handwashing and cover her nose and mouth when sneezing. These efforts will reduce others' exposure to molecules that can elicit an immune response or:

A) antigens.
B) epitopes.
C) haptens.
D) immunogens.

Question 15

The nurse is providing medication to a client in order to improve the function of the client's antibodies. Which of the following are considered antibody functions? (Select all that apply.)

A) Neutralization
B) Agglutination
C) Opsonization
D) Activation of inflammation
E) Phagocytosis
F) Activation of complement

Question 16

The nurse is reviewing the results of a laboratory test to measure the amount of immunoglobulins in a client's blood. Which of the following should have the highest value?

A) IgA
B) IgG
C) IgM
D) IgE

Question 17

A client tells the nurse that he is allergic to Valium because he experienced nausea, vomiting, and dizziness after ingesting. How should the nurse document this information?

A) Client is allergic to Valium.
B) Client does not want to be prescribed Valium.
C) Valium has caused an allergic reaction in this client.
D) Client experiences nausea, vomiting, and dizziness after ingesting Valium.

Question 18

The mother of a newborn baby is concerned that the baby will develop illnesses from being around so many people. The nurse should explain that the baby has immunity that is present at birth or:

A) acquired immunity.
B) adaptive immunity.
C) innate immunity.
D) specific immunity.