Question 1

A client asks, "Why does the infection in my finger make it so red?" What is the nurse's best response?

Accepted Answer

When the body detects an infection, it sends more blood to the area to increase the immune response and deliver antibodies and nutrients to the site of infection. This increased blood flow causes the area to become red and hot to the touch.

Question 2

The nurse has explained the process of phagocytosis to a client with an infected wound. He asks the nurse why these cells do not eat good cells as well? How should the nurse respond?

Accepted Answer

Phagocytic cells have the ability to distinguish between self and non-self cells. This is known as self-tolerance and is critical for proper immune system function. Therefore, these cells will only attack and consume foreign or abnormal cells, leaving healthy cells untouched.

Question 3

A client is prescribed an antihistamine for an allergic reaction. The client asks, "Why am I getting this? What is a histamine anyway?" How can the nurse most accurately describe the action of histamine in the body?

Accepted Answer

Histamine causes blood vessels to dilate, which increases blood flow and causes swelling and itching. It also increases vascular permeability, which leads to leakage of fluid out of the blood vessels and into the surrounding tissues, resulting in swelling or edema. This is why an antihistamine is prescribed to counteract the effects of histamine in an allergic reaction.

Question 4

Which cells of the nonspecific body defence are phagocytic? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of Which cells of the nonspecific body defence...

Question 5

A client has been stung by a bee. The site is warm, red, and swollen. Which agent does the nurse suspect to be the cause?

Accepted Answer

Histamine is responsible for the immediate symptoms of an allergic reaction, such as warmth, redness, and swelling, following a bee sting.

Question 6

During assessment of a client's infection site, the nurse determines that the site is warm to the touch. How should the nurse explain this warmth to the client?

Accepted Answer

The warmth at the infection site is due to increased blood flow and white blood cells being sent to the area to fight the infection. Option A is incorrect because infection generally causes dehydration rather than fluid overload. Option B is incorrect because the lymphatic system is actually involved in fighting infection and does not shut down. Option C is incorrect because leaking vessels would cause swelling, but not necessarily warmth.

Question 7

A client scheduled to undergo a lymph node biopsy asks, "If lymph nodes are so prone to cancer, why don't they just take them all out?" How should the nurse respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Lymph nodes play an important role in filtering out toxins, debris, and infection from the body. They also contain cells that help protect the body from cancer cells. While it is true that some lymph nodes may need to be removed during a biopsy or surgery, it is not typically necessary to remove all of them unless the client has a specific condition such as lymphoma.

Question 8

A client says, "The doctor says I have a problem with the fluid in my lymph system backing up. Where does lymph fluid come from?" How should the nurse respond?

Accepted Answer

Lymph fluid comes from the liquid part of the blood, which is called plasma. The fluid is filtered through the walls of small blood vessels and picked up by the lymphatic vessels, where it is transported and filtered by lymph nodes.

Question 9

A client asks, "Why does my leg swell when I have an infection?" How should the nurse respond?

Accepted Answer

When the body is infected, it triggers an inflammatory response. One of the reactions is the release of small proteins that make the blood vessels more permeable. This allows fluid and immune cells to move to the site of infection, resulting in swelling and redness. In the case of leg swelling, the infection causes the little vessels in the leg to become leaky, and fluid seeps out of the blood, leading to edema.

Question 10

A client is prescribed ibuprofen for pain. The nurse is aware that this drug is designed to target which inflammatory mediator to reduce pain?

Accepted Answer

Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that works by inhibiting the production of prostaglandins, which are inflammatory mediators that play a key role in the perception of pain. By blocking the production of prostaglandins, ibuprofen can reduce pain and inflammation.

Question 11

A client with a disorder of the plasma cells has a deficiency in which part of the immune system?

Accepted Answer

Plasma cells are responsible for producing immunoglobulins (antibodies) that specifically target and bind to antigens. Patients with disorders of the plasma cells have a deficiency in this part of the immune system because they are unable to produce adequate amounts of functional antibodies.

Question 12

The infection control (IC) nurse has completed teaching newly hired nurses about the innate body defence. Which statements by one of the participants would indicate the need for further instruction? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Statement B is incorrect as complement is a component of the innate immune response, not the adaptive immune response. Statement D is also incorrect as dendritic cells are not part of the nervous system, but rather part of the immune system and are involved in presenting antigens to activate T cells. Statements A, C, and E are all correct.

Question 13

A key aspect of the specific immune system is:

Accepted Answer

The specific (or adaptive) immune system is characterized by its ability to remember and recognize specific pathogens after the initial encounter, providing long-term protection against future infections. This memory function is critical for the success of vaccines, which rely on the ability of the immune system to develop memory cells that can rapidly respond to a pathogen upon subsequent exposure. Recognition of common bacterial receptors and the role of phagocytes are functions of the innate immune system, while complement is a component of both the innate and adaptive immune systems.

Question 14

The newly licensed nurse tells her clinical educator, "I thought that interferons were medications, but I heard the doctor tell my client that his interferons were suppressed." How should the educator respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Interferons are proteins produced by the body that play a role in the immune response. They can also be manufactured as medications to treat certain conditions like cancer. Interferons help stimulate other immune cells.

Question 15

Which option reflects a key aspect of the nonspecific body defence?

Accepted Answer

Inflammation is a key aspect of the nonspecific body defense. It occurs in response to tissue injury, infection or irritation and involves the release of chemical signals to stimulate blood flow to the affected area, and the migration of white blood cells to fight off any potential invaders. It is a non-specific response as it occurs in the same way regardless of the specific pathogen causing the injury or infection.

Question 16

Activation of the humoral immune system by an antigen results in the production of which substance?

Accepted Answer

Activation of the humoral immune system results in the production and secretion of immunoglobulins (antibodies) specific for the antigen which can attach to the antigen and help eliminate it from the body. Macrophages are not produced by the humoral immune system. Sensitized T lymphocytes and natural killer (NK) cells are part of the cell-mediated immune response, not the humoral immune response.

Question 17

The school nurse is speaking to a group of children in middle school about preventing infection. How can the nurse best explain why it is so important for the children to keep from injuring their skin? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of The school nurse is speaking to a...

Question 18

Which properties are common to both the cell-mediated and humoral immune systems? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Both the cell-mediated and humoral immune systems have memory, which allows for a more rapid response upon subsequent exposure to a specific antigen. They also have specificity, meaning they can recognize and react to molecules bearing a specific marker. Neither system reacts in the same way regardless of the nature of the offending agent; they each have unique mechanisms and responses for different types of pathogens. Recognition of common pathogenic features in bacterial cell walls is more relevant to the cell-mediated immune system, while the response of helper T cells is more relevant to the humoral immune system. Therefore, the best choices are C and D.

Question 19

What is the purpose of the normal flora of the skin?

Accepted Answer

The normal flora of the skin competes with potential pathogens for nutrients and space, helping to prevent harmful bacteria and viruses from colonizing and causing infections.

Question 20

A client has been diagnosed with cancer. The nurse plans an assessment based on the awareness that cancer can spread through which component of the lymphatic system?

Accepted Answer

Cancer cells can spread through the lymphatic system via the lymph vessels. Tonsils, thymus gland, and spleen are also part of the lymphatic system, but they are not directly involved in the spread of cancer cells.

Quiz 9: Pharmacology of Alterations in Body Defences