Question 1

The nurse is providing care to a patient with a compromised immune system.Which independent nursing intervention is appropriate for the nurse to include in the patient's plan of care?

Accepted Answer

Educating on the importance of a nutritious diet is an independent nursing intervention appropriate for a patient with a compromised immune system. A nutritious diet is essential for improving and maintaining immune function, which is essential for preventing infection in patients with compromised immune systems. Gene transfer therapy is not a nursing intervention and is outside the scope of practice. Corticosteroids and prophylactic antibiotic therapy are medical interventions that require a physician's order.

Question 2

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?

Accepted Answer

An 88-year-old with pneumonia and a low-grade fever of 99.5°F demonstrates a decline in immune response, as older adults often have a blunted fever response to infections.

Question 3

Which nutritional deficiency often impacts a patient's ability to mount an immune response?

Accepted Answer

Proteins are essential for the production of antibodies and immune cells, and a deficiency can impair immune function. The other options are important for various bodily functions, but do not have a direct impact on immune response.

Question 4

The nurse is providing care to a patient who has a decreased neutrophil count and elevated hepatic enzymes.Which data in the patient's health history supports this laboratory data indicating an increased risk for infection?

Accepted Answer

Cirrhosis of the liver can lead to a decreased neutrophil count and elevated hepatic enzymes, which increases the risk for infection. Anorexia nervosa may lead to a decreased neutrophil count, but does not typically impact hepatic enzymes or increase the risk for infection. Acute renal failure and pulmonary disease may impact laboratory values, but are not typically associated with an increased risk for infection based solely on these laboratory results.

Question 5

Which type of immunoglobulin (Ig)is produced during an allergic reaction?

Accepted Answer

IgE is the immunoglobulin that is primarily involved in allergic reactions. It is produced in response to an allergen and binds to mast cells and basophils, triggering the release of histamine and other inflammatory mediators.

Question 6

Which nursing action is appropriate when assessing a patient's tonsils during a physical examination?

Accepted Answer

When assessing a patient's tonsils during a physical examination, the appropriate nursing action is to ask the patient to open their mouth and say "ah." This allows the nurse to visualize the tonsils and assess their size and condition. Asking the patient to cough or palpating other areas of the body would not be relevant to assessing the tonsils.

Question 7

The nurse is providing care to a patient who has an increased number of lymphocytes.Which explanation should the nurse provide to the patient regarding this abnormality?

Accepted Answer

The answer of The nurse is providing care to a...

Question 8

The nurse is conducting a health history for a patient who is at risk for infection.Which question is appropriate when collecting data related to the patient's past medical history?

Accepted Answer

The spleen is an important organ in the immune system. Its removal can increase the risk of infection.

Question 9

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?

Accepted Answer

Leukocytosis is an increase in the number of white blood cells, which can indicate the presence of an infection. Therefore, the most appropriate action by the nurse is to assess for the source of infection. Assessing for bleeding and bruising would be more relevant to a patient experiencing thrombocytopenia. Placing the patient in reverse isolation precautions would be more relevant to a patient experiencing neutropenia. Instructing the patient on the use of an electric razor and soft toothbrush would be more relevant to a patient experiencing thrombocytopenia or coagulopathy.

Question 10

The nurse is providing care to a patient who experienced an allergic reaction.Which leukocyte does the nurse anticipate will be elevated?

Accepted Answer

Basophils are a type of white blood cell that plays a role in allergic reactions. When the body detects an allergen, it releases histamine and other chemicals that cause symptoms such as itching, swelling, and redness. Basophils contain granules of histamine and other chemicals that are released during an allergic reaction. Therefore, an elevation in basophils is expected in patients experiencing an allergic reaction.

Question 11

Which laboratory test should the nurse anticipate for a patient who reports chronic inflammation?

Accepted Answer

Chronic inflammation can cause an elevated ESR, which measures the rate at which red blood cells settle to the bottom of a tube in a specific amount of time. A high ESR indicates inflammation or infection. The other test options (varicella titer, type and crossmatch, CBC with differential) are not specific to chronic inflammation.

Question 12

The nurse is providing care to patient who is at an increased risk for infection due to poor dietary intake,a decreased white blood cell count,and diminished neutrophil activity.Which information in the patient's health history supports the current data?

Accepted Answer

Anorexia nervosa is an eating disorder that can result in poor dietary intake, which can lead to malnutrition and a weakened immune system. This puts the patient at increased risk for infection.

Question 13

Which physiological barriers protect the patient's body against microorganisms?

Accepted Answer

Adequate urinary output helps to flush out microorganisms from the body and prevent their growth and colonization. Surgical incisions can actually increase the risk of infections, while smoking and alcohol consumption can weaken the immune system and make the body more susceptible to infections.

Question 14

The nurse is teaching a new mother the immune benefits of breastfeeding her newborn.Which immunoglobulin (Ig)should the nurse include as one that is passed from mother to newborn by breast milk?

Accepted Answer

IgA is the immunoglobulin passed from mother to newborn through breast milk. It plays an important role in providing the newborn's immune system with protection against respiratory and gastrointestinal infections. IgD and IgE are not typically found in breast milk, and while IgG can be present, it is not as prominent as IgA.

Question 15

Which scenario should the nurse provide as one in which active immunity is acquired when educating a group within the community?

Accepted Answer

Active immunity is acquired when the body is exposed to a disease-causing organism and produces its own antibodies, as in the case of having measles as a child.

Question 16

The nurse is providing care to a patient who had the spleen removed after a car accident.Which type of infection is this patient at an increased risk for experiencing?

Accepted Answer

The spleen is an important organ in the body's immune system that helps fight off bacterial infections. When it is removed, the body's ability to fight certain types of bacteria, such as Streptococcus pneumoniae, is reduced, increasing the patient's risk for bacterial infections. Therefore, the patient is at an increased risk for bacterial infections.

Question 17

The nurse is teaching a group of patients about first-line defense against infection.Which patient statement indicates the need for further education?

Accepted Answer

A cut with pus is not a first-line defense against infection, but rather an indication of a breach in the body's defenses and a potential site for infection. The other statements correctly identify first-line defenses against infection.

Question 18

The nurse is conducting a health history for a patient who is at risk for infection.Which question is appropriate when collecting data related to the current problem?

Accepted Answer

The answer of The nurse is conducting a health history...

Question 19

The nurse is conducting a health history for a patient who is at risk for infection.Which question is appropriate when collecting data related to the patient's social history?

Accepted Answer

Asking about smoking is appropriate when collecting social history as it is a risk factor for infection. Immunizations, allergies, and spleen status are all pertinent to medical history, not social history.

Question 20

Which question should the nurse to ask during a health history with an adolescent patient,accompanied by a parent,to determine immune status?

Accepted Answer

Asking about the patient's immunization status is the best way to determine their immune status. This information is important for disease prevention and for protecting the patient and the wider community. The other questions are important to ask for overall health assessment, but do not directly relate to determining immune status.

Quiz 18: Assessment of Immune Function