NR - 324 Exam 3 - Immune System Alterations Questions with 100% accurate solutions - Chamberlain University

How a vaccine works

A weakened form of the disease antigen (may be dead or living) is injected

-The body reacts to the antigen creating Antibodies to destroy it

-If the antigen is ever in the body again, the body's immune system antibodies will be able to fight against it

Type 1 hypersensitivity reaction

immediate hypersensitivity

describe Type 1 hypersensitivity reaction

-Onset w/in a few minutes of antigen challenge

-Ex: allergies to molds, insect bites

-localized allergic reaction

Type III hypersensitivity reaction

Immune-complex reaction

describe Type III hypersensitivity reaction

(immune-complex reaction)

-the antigen combines with the

antibody, forming a complex, which is then deposited

in tissue, often in blood vessel walls, and also activates

complement

-Onset usually w/in 2-6 hours

-Ex: serum sickness and systematic lupus erythematosus, Rheumatoid arthritis

Anaphylaxis is a type ___ hypersensitivity reaction

I

Allergic Rhinitis

hay fever

-the most common type 1 hypersensitivity reaction

-can occur all year round. can be seasonal

Primary causes of Allergic Rhinitis

-Dust

-Pollen

-Molds

-Animal dander

manifestations of Allergic Rhinitis

-Red, itchy, watery eyes

-Sneezing, congestion, runny nose

-Itchy or sore throat, post-nasal drip, cough

causes of anaphylaxis

-Insect stings (bee, wasp, ant)

-Medications and Latex

-Food allergy (peanuts, eggs, shellfish)

Manifestations of Anaphylaxis

Rapid onset

-Dyspnea (tight throat, bronchospasm, Laryngeal edema)

-Feelings of apprehension, HA (dilation)

-Tingling and swelling in mouth, face, throat, and tongue

-Itching

-FVD (vessels dilate = fluid loss)

-↓BP

-Tachycardia

-Loss of consciousness

-Edema

-Erythema

Interventions for Anaphylaxis

-EpiPen: vasoconstriction, bronchodilation, short-acting

-Assess respiratory function; establish airway

-CPR (if needed)

-Epinephrine

-Antihistamines (for angioedema and urticaria)

-Oxygen

-Treat bronchospasm

-IV fluids

HIV targets which cell type?

CD4, T cell

HIV manifestations

Acute infection

· Seroconversion: when HIV-specific antibodies develop → accompanied by Fever, Swollen lymph glands, sore throat, HA, malaise, nausea, muscle and joint pain, diarrhea, and/or a diffuse rash

· Some develop neuro conditions (aseptic meningitis, peripheral neuropathy, facial palsy, or Guillian-Barre syndrome)

· Many people, including HCPs, mistake Acute HIV symptoms as a bad case of the flu

Chronic HIV infection

· Asymptomatic infection - CD4 T-cells >500 cells/uL

· Fatigue, HA, low-grade fever, night sweats, persistent generalized lymphadenopathy (PGL)

· Symptomatic Infection - CD4 T-cells = 200-500 cells/uL

· Symptoms in early in phases become worse

· Persistent fever, freq. drenching night sweats, chronic diarrhea, recurrent headaches, and fatigue severe enough to interrupt normal routines

· Localized infections, lymphadenopathy, and Nervous system manifestations

· Oropharyngeal candidiasis (thrush) - most common infection

· Less common - shingles, persistent vaginal candidal infections, outbreaks of oral or genital herpes, bacterial infections, and Kaposi Sarcoma (KS)

· Oral hairy leukoplakia - infection that causes painless, white, raised lesions on the lateral aspects of the tongue

· AIDS

· Many infections, variety of malignancies, wasting, and HIV-related dementia can occur

Several opportunistic diseases may occur at the same time

In HIV, when the CD4 cells are ______ than 500, they can fight infection

greater than 500

When is HIV considered AIDS?

When the CD4 T cells are under 200

Ways HIV can be transmitted

Blood, semen, vaginal secretions, and breast milk

Prevention of transmission of AIDS in health care setting

-Maintain Standard precautions: Handwashing/hygeine, Protective barriers (gloves, mask, eye shield, Gown)

-Do NOT recap needles

-Clean up spills of blood and body fluid immediately using Germicidal solution

-Consider ALL body fluids to be contaminated

-Avoid contaminating he outside of specimen containers

-Cleanse work surface areas w/ appropriate germicide

lab values we are looking for in HIV/AIDS?

CD4 & Viral load

-we want the CD4 ↑, and the viral load ↓

Collaborative care for HIV/AIDS

· Monitoring HIV disease progression

· Initiating and monitoring ART

· Preventing the development of opportunistic diseases

· Detecting and treating opportunistic diseases

· Managing symptoms

· Preventing / decreasing complications of treatment

· Preventing further treatment of HIV

· Case reporting the health department

· Patient teaching on transmission of HIV

Laboratory tests

Management of HIV/AIDS

· Primary prevention and health promotion are the most effective health care strategies

· encourage the patient to adopt safer, healthier, and less risky behaviors.

· Encourage Pt to limit sexual partners

· Encourage Pt to use safe sex measures

· Encourage Pt to abstain from Drugs, if drugs are used, do not share equipment, or have sex while intoxicated

· Encourage strict adherence to drug regimen to decrease risk of resistance

· Promote a healthy immune system (avoid alcohol & tobacco, nutritional support, vaccines, rest & exercise, avoid exposure to new infections, ↓ stress, mental health, support groups, consistent relationship w/ HCPs)

The best way to prevent opportunistic disease is to ensure that the patient is adhering to an effective ART regimen and, if appropriate, taking prophylactic medications for opportunistic infections

A nurse is caring for a 20 year-old client who is sexually active and has come to the college health clinic for a first-time checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention?

a. Measure vital signs

b. encourage HIV screening

c. Determine risk factors

d. Instruct client to use condoms

c

SLE

systemic lupus erythematosus

Define Systematic Lupus Erythmatosus (SLE)

a multisystem inflammatory autoimmune disease - typically affects the skin, joints, and serous membranes, renal, hematologic, and neurological systems

-characterized by a chronic unpredictable course marked by alternating periods of exacerbation and remission

-Extremely variable in its severity

-most commonly affected tissues: skin and muscle, lining of lungs, heart, nervous tissue, and kidneys

Manifestations of SLE

Generalized complaints (fever, weight loss, arthralgia (joint pain), and excess fatigue may precede an exacerbation)

-Photosensitivity

-Butterfly rash over cheeks

-Tachypnea, cough, Pleural effusion

-Hematologic disorders

-muscle stiffness

-Reynaud's phenomenon

Pt teaching for SLE

· Disease process

· Names of drugs, actions, side effects, dosage, administration

-medications target inflammation and immunosuppression

· Pain management strategies

-Stay hydrated

-Identify s/s of Infection

· Energy conservation and pacing techniques

· Therapeutic exercise, use of heat therapy (arthalgia)

· Avoidance of physical and emotional stress

· Avoidance of exposure to individual with infections

· Avoidance of drying soaps, powders, household chemicals

· Use Sunscreen (at least SPF 30) and protective clothing, minimal sun exposure btw 1100 and 1500

· Regular medical and lab follow-up

· Martial and pregnancy counseling as needed

Community resources and health care agencies

Anitmalarials complication

Can cause eye issues - Retinopathy

The client with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? (Select all that apply)

1. Use sunscreen of SPF 30 or greater when in the sunlight.

2.Notify the HCP immediately when developing a low-grade fever.

3.Some dyspnea is expected and does not need immediate attention.

4.The hands and feet may change color if exposed to cold or heat.

5.Explain the client can be cured with continued uninterrupted therapy.

1, 2, 4

A client diagnosed with an autoimmune disorder questions the nurse as to what impact this may have on activities of daily living in the years to come. What is the best response that the nurse can give?

1."The changes will be subtle at first so it won't be noticeable to others."

2."It is hard to predict what the disease process has in store for any individual."

3."I can hear the concern in your voice. Perhaps we can talk for awhile and discuss some of your concerns."

4."I would suggest the use of any available remedy that might give you some comfort."

2

A nurse is reviewing the laboratory results of a client who is postoperative. Which of the following laboratory findings should the nurse identify as an indication of postoperative infection?

(Select all that apply.)

1) Increased band neutrophils

2) Elevated erythrocyte sedimentation rate (ESR)

3) Absence of ketones in urine

4) Negative leukocyte esterase in urine

5) Increased hemoglobin

6) Increased white blood cell (WBC) count

1, 2, 6

manifestations of Sepsis: TIME

Temperature (higher or lower than normal)

Infection (may have s/s of infection, SOB)

Mental decline (confused, sleepy, difficult to arouse)

Extremely ill (severe pain or discomfort)

populations at risk for Sepsis

-Elderly

-Immunocompromised

-chronic illnesses

-Surgical Pts

-Trauma Pts

Goals in the treatment of Sepsis

-Maintain tissue perfusion

-Maintain normal BP

-Avoid complications from hypo-perfusion (protect organs, protecting kidneys)