Ch 16: Concepts of Inflammation and Immunity (Evolve Questions)

The nurse is caring for a client experiencing sneezing, rhinorrhea, and a dry throat associated with a change in the pollen count. Which laboratory finding would the nurse anticipate?

A. Increased band count

B. Reduction in basophils

C. Elevation in eosinophils

D. Low overall neutrophil count

C

The number of circulating eosinophils increases during an allergic response such as when the body responds to the presence of pollen (Choice C). Infection—not an allergic response—usually induces an increase in band count (Choice A). Basophils (Choice B) and neutrophils (Choice D) increase during an allergic response.

The nurse is assessing an older adult with a 4-inch reddened wound on the abdomen. When pus is noted draining from the wound, which of the following nursing actions is appropriate? Select all that apply.

A. Take the client's temperature.

B. Seal an adhesive dressing over the wound.

C. Disinfect the wound with alcohol and betadine.

D. Contact the primary health care provider to request an antibiotic.

E. Photograph and document the wound appearance in the health record.

A, D, E

The client needs to be assessed for signs of a systemic infection, which may be indicated by an elevation in temperature (Choice A). The nurse will contact the primary health care provider to request an antibiotic, as pus is a sign of infection (Choice D). The nurse will also photograph and document the wound's appearance in the health record, keeping in mind that the photograph is not to be placed anywhere other than in the health record to comply with privacy law (Choice E). This action will be beneficial when monitoring for healing, as the dimensions and appearance of the wound can be noted over time. The nurse will not place an adhesive dressing over the wound until the health care provider has assessed it, as this would seal in infection and increase the risk for complications (Choice B). Alcohol and betadine could be very abrasive to tissue, so these methods of cleansing should be avoided (Choice C).

The nurse is caring for four clients. Which client would the nurse identify as benefiting from the use of convalescent serum?

A. Client who had COVID-19 last month and is recovering well at home

B. Client who tests negative after being around someone with COVID-19

C. Client who is immunocompromised and has tested positive for COVID-19

D. Client who is negative for COVID-19 yet has upper respiratory symptoms

C

The client who is immunocompromised and has just tested positive for COVID-19 is most likely to benefit from convalescent serum (Choice C). Although there are not guidelines that prohibit other clients with COVID-19 from having this treatment, current evidence shows that those who have a severe case or a risk for a severe case and who receive the treatment within 72 hours of symptom onset benefit most. Convalescent serum would not greatly benefit a client who is recovering well at home after having COVID-19 last month (Choice A). It is unlikely that convalescent serum will be given to someone who tested negative but had been around someone with COVID-19 (Choice B). A client with upper respiratory symptoms who is COVID-19 negative will be assessed further to determine which treatment is appropriate; convalescent serum would not be used since the client tested negative (Choice D).

The nurse is caring for a client whose white blood cell count is 6000/mm3. Which differential value would the nurse discuss with the health care provider?

A. Eosinophils 700/mm3 (Reference range: 50-400/mm3)

B. Monocytes 500/mm3 (Reference range: 100-800/mm3)

C. Lymphocytes 2400/mm3 (Reference range: 1000-4000/mm3)

D. Segmented neutrophils 3000/mm3 (Reference range: 2500-7000/mm3)

A

The nurse will discuss the elevated eosinophil count with the health care provider (Choice A). All other values are within expected parameters (Choices B, C, and D).

The nurse is providing teaching to a client who is to receive a vaccination following a deep puncture wound to the foot. Which information would the nurse include?

A. "You will need to receive this vaccination annually."

B. "Your passive immunity will be boosted by receiving this shot."

C. "I am administering this vaccination to help protect you against tetanus."

D. "This immunization requires three separate injections several weeks apart."

C

The nurse will provide teaching that confirms that the immunization is meant to protect the client from development of tetanus, an infection caused by the bacterium Clostridium tetani (Choice C). This bacterium often enters the body through a puncture wound—for example, from stepping on a nail. This vaccination is given to adults every 10 years, not annually (Choice A). Artificial active immunity occurs following immunization, not a boost in passive immunity (Choice B). Immunization is accomplished via one injection—not three separate injections given several weeks apart (Choice D).

Which cell types provide protective responses during inflammation?

A. Platelets

B. Basophils

C. Macrophages

D. Natural killer cell

E. Eosinophils

C

Macrophages and neutrophils initiate and complete phagocytosis against invading microorganism, providing the body with protection against infection. Platelets have no direct role in the protection provided by inflammation. Basophils and eosinophils are responsible for vascular changes, not protection. Natural killer cells are not particularly active during inflammation.

The nurse is caring for a client with no known health diagnoses. Which assessment finding prompts the nurse to further assess the client's immunity?

A. Has old scar formation related to an appendectomy.

B. Has poor oral hygiene and numerous dental caries.

C. Displays occasional skipped heartbeats during auscultation.

D. Displays orthostatic hypotension and is mildly dehydrated.

B

Poor oral hygiene and untreated dental carries are sources of infectious organisms with access to the blood (because mucous membranes are no longer intact). This is a potential threat to immunity because the condition can cause chronic inflammation and a constant transfer of microorganisms to the bloodstream, which increases the risk for systemic infection. Old scar formation, occasional skipped heartbeats, and orthostatic hypotension with mild dehydration need to be further assessed, yet they are not a threat to the immune system.

How will the nurse interpret a client's white blood cell count that has a total count of 8000 cells/mm3 (8 × 109/L) with a lymphocyte count of 4100 cells/mm3 (4.1 × 109/L)?

A. The client is most likely in good health.

B. The client most likely has a viral infection.

C. The client most likely has a bacterial infection.

D. The client most likely has depressed immunity due to a chronic condition.

B

Although the total white blood cell count is within the normal range, the lymphocyte count is elevated. The most common cause of lymphocyte count elevation is an actual viral infection. Other interpretations are incorrect.

Which number will the nurse calculate as the absolute neutrophil count (ANC) for a client whose differential includes: total WBCs 5300/mm3 (5.3 × 109/L ); segs 2800/mm3 (2.8 × 109/L); bands 200/mm3 (0.20 × 109/L); monos 250/mm3 (0.25 × 109/L); lymphs 2000/mm3 (2.0 × 109/L); eosins 25/mm3 (0.025 × 109/L); basos 25 (0.025 × 109/L)?

A. 2300/mm3 (2.3 × 109/L)

B. 2800/mm3 (2.8 × 109/L)

C. 3000/mm3 (3.0 × 109/L)

D. 3200/mm3 (3.2 × 109/L)

C

The absolute neutrophil count is calculated by adding the mature neutrophil count (segs) with the slightly less mature band neutrophil count (which will mature within a matter of hours into segs). Monos, lymphs, eosins, and basos are not neutrophils.

Which differential count will the nurse report to the primary health care provider for a client whose white blood count indicates a total count of 10,000 cells/mm3 (10 × 109/L)?

A. Eosinophils 200/mm3 (0.2 × 109/L)

B. Monocytes 2000/mm3 (2 × 109/L)

C. Segmented neutrophils 6000/mm3 (6 × 109/L)

D. Lymphocytes 2100/mm3 (2.1 × 109/L)

B

The normal monocyte population in peripheral blood should be not greater than 5%. A monocyte count of 2000 in 10,000 white blood cells represents 20% of the total and indicates a significant increase, so this needs to be reported. Other values do not require reporting at this time.

The nurse is caring for a client with a high blood concentration of IgG directed against the human papilloma virus. How does the nurse interpret this laboratory finding?

A. The client is in the midst of their first response to human papilloma infection.

B. The client is at risk for major hypersensitivity reactions to attenuated vaccines.

C. The client is having an appropriate response to a recurrent exposure to the virus.

D. The client is at increased risk for becoming ill from opportunistic infectious organisms.

C

When naive B-cells become sensitized to a specific microorganism, they divide forming plasma cells and memory cells, both of which retain the antigen sensitization. The plasma cell immediately begins to secrete antibodies in the form of immunoglobulin M (IgM) against the microorganism. Upon later re-exposure to the same antigen, memory cells will secrete immunoglobulin G (IgG) against it. Therefore the presence of high concentrations of specific IgG in the blood indicates a normal immune response to recurrent infection to the same viral infection. Option A is incorrect because an initial exposure would be indicated by increased IgM levels against the microorganism, not IgG. Option B is incorrect because IgG does not mediate hypersensitivity reactions. Option D is incorrect because the presence of high levels of IgG does not indicate a decline in the client's immune status.

Which client laboratory response indicates to the nurse that granulocyte colony-stimulating factor therapy is successful?

A. Increased platelets

B. Increased lymphocytes

C. Increased red blood cells

D. Increased white blood cells

D

Granulocyte colony-stimulating factor is a growth factor that stimulates the increased production and maturation of neutrophils. This action increases the circulating number of neutrophils and has minimal effect on other blood cell types. Other options do not indicate that granulocyte colony-stimulating factor therapy is successful.

The nurse is caring for a client who has a large wound and states, "I just had a tetanus booster shot last year." Which response will the nurse provide?

A. "You instead will need a zoster recumbent vaccination."

B. "You need this vaccination as a booster to the one you had a year ago."

C. "You may not need this vaccination now; I will check with your health care provider."

D. "You need this vaccination because the strain of tetanus changes every year."

C

If this client's medical records substantiate that a tetanus toxoid booster shot 1 year ago, they may not need another one at this time. Therefore, the nurse will check with the health care provider to confirm. This vaccination is good for approximately 10 years. A zoster recumbent vaccination is not related to a large wound. Another booster is not needed. The strain of tetanus does not change.

Which assessment finding does the nurse anticipate in a client with very few regulator T cells?

A. Increased severity of allergic reactions

B. Decreased ability to recognize non-self cells

C. Decreased immunoglobulin production

D. Increased risk for cancer development

A

Regulator T-cells (Tregs) function to limit the actions of general and specific responses. These cells prevent over-responses to the presence of "foreign proteins" within a person's environment. People who are deficient in these cells have more severe hypersensitivity reactions, allergies, and autoimmune responses. Other reactions are not expected.

Which precaution will the nurse to teach a client who has few natural killer cells that are not very active?

A. "You will no longer develop a fever when you have an infection."

B. "You will be at an increased risk for developing allergies."

C. "You will no longer be able to develop antibodies."

D. "You will be at a higher risk for cancer development."

D

Natural killer cells provide protection against development of cancer by recognizing unhealthy or cancer cells as non-self and taking action to destroy them.

Which client health problems will the nurse identify as infectious? (Select all that apply.)

A. Appendicitis

B. Anaphylaxis

C. Asthma

D. Cystitis

E. Sepsis

F. Tendonitis

A, D, E

Appendicitis, cystitis, and sepsis are infectious. Other processes are inflammatory but not infectious.

Which client health problems will the nurse identify as inflammatory without infection? (Select all that apply.)

A. Acute myocardial infarction

B. Blister formation from a burn

C. Poison ivy rash

D. Otitis media

E. Welt formation after a bee sting

A, B, C, E

Inflammation is nonspecific response to tissue injury, irritation, and invasion by organisms or allergens. Acute myocardial infarction, blister formation from a burn, poison ivy rash, and a welt formation following a bee sting are types of issue injury, irritation, or invasion as the pathophysiologic mechanism causing the response. Otitis media is a bacterial infection.

The nurse is providing health teaching to an 82-year-old client. Which precautions will the nurse share? (Select all that apply.)

A. Get an influenza vaccination every year.

B. Wear gloves when working in your garden.

C. Avoid performing aerobic exercise.

D. Have a tuberculosis skin test every year.

E. Report any temperature elevation to your provider.

A, B

Older clients have overall reduced immunity and a higher risk for developing influenza and any other respiratory tract infection. They should receive annual influenza vaccinations. The skin of older adults is thinner, drier, and a greater risk for injury and infection. Wearing gloves when gardening can help prevent injury and reduce the risk for infection. Older clients often do not have greatly elevated temperatures during infection, which contributes to the infection being overlooked until it becomes serious. Thus, older clients should report any increase in temperature above their normal range to identify infections at earlier stages. Older clients can still engage in low-impact aerobic exercise under the supervision of their primary health care provider. TB skin tests may be falsely negative in older clients with reduced immunity and annual testing is of no real benefit.

Which assessment finding does the nurse anticipate in a client who does not make adequate amounts of immunoglobulin A (IgA)? (Select all that apply.)

A. Contact dermatitis

B. Cystitis

C. Diarrhea

D. Excessive bleeding

E. Upper respiratory infections

B, C, E

Cystitis, diarrhea, and upper respiratory infections are anticipated. IgA is the secretory immunoglobulin that is present in highest concentrations in the secretions of the mouth, gastrointestinal tract, and genitourinary tract. IgA helps prevent infections in these body areas and does not circulate in significant amounts. It is not associated with any types of allergic reactions such as anaphylaxis or contact dermatitis. It plays no role in the blood clotting cascade, so bleeding is not anticipated.