Chapter 55: Care of the Patient with an Immune Disorder

Which of the following is an example of immunocompetence?

a. A child that is immune to measles because of an inoculation

b. A person who has seasonal allergies every fall

c. When the symptoms of a common cold disappear in 1 day

d. A neonate having a natural immunity from maternal antibodies

c. When the symptoms of a common cold disappear in 1 day

Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimulus and the body's integrity is maintained as with cold symptoms that resolve with residual illness.

p. 1962

An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse's first intervention?

a. Apply cool compresses to urticaria

b. Provide oxygen per non-rebreathing mask

c. Cover patient with a warm blanket

d. Prepare for venipuncture for the delivery of IV medication

b. Provide oxygen per non-rebreathing mask

Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention.

p. 1971

What is the etiology of autoimmune diseases based on?

a. Reaction to a "superantigen"

b. Immune system producing no antibodies at all

c. T cells destroying B cells

d. B and T cells producing autoantibodies

d. B and T cells producing autoantibodies

Autoimmune disorders are failures of the tolerance to "self." B and T cells produce autoantibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish "self" protein from "foreign" protein.

p. 1974

A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing plan of care should include provisions for:

a. infection control.

b. supporting self-care.

c. nutritional education.

d. maintaining high fluid intake.

a. infection control.

Immune deficient persons are at risk for infection and need to be protected aggressively for contagion.

p. 1973

The nurse takes into consideration that when the antigen and antibody react, the complement system is activated which:

a. toughens the cell wall.

b. generates more T cells.

c. attracts phagocytes.

d. makes the antigen resistant.

c. attracts phagocytes.

The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes.

p. 1966

How does normal aging change the immune system?

a. Depresses bone marrow

b. T cells become hyperactive

c. B cells show deficiencies in activity

d. Increase in the size of the thymus

c. B cells show deficiencies in activity

Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is essentially uncompromised. The thymus decreases in size.

p. 1966

What would the nurse recommend for a 94-year-old home health patient with deteriorated cell-mediated immunity?

a. Avoiding the influenza vaccine

b. Getting pneumonia vaccine

c. Having skin tests for all antigens

d. Taking large doses of beta-carotene

b. Getting pneumonia vaccine

As the older adult loses some of the cell-mediated immunity, especially against pneumonia and influenza, it is recommended that they acquire the immunization.

p. 1966

A patient who works in a plant nursery and has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment?

a. "I need to think about a change in my occupation."

b. "I will learn to administer epinephrine so that I will be prepared if I am stung again."

c. "I should wear a Medic-Alert bracelet indicating my allergy to insect stings."

d. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

d. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

The nurse's responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance doses of corticosteroids because this was a short, rapid reaction.

p. 1970

What is the substance released by the T cells that stimulates the lymphocytes to attack an inflammation?

a. Lymphokine

b. Epinephrine

c. B cells

d. Histamine

a. Lymphokine

Lymphokines help attract macrophages to the site of the inflammation.

p. 1964

Immediately after the nurse administers an intradermal injection of a suspected antigen during allergy testing, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially?

a. Elevate the arm above the shoulder

b. Administer subcutaneous epinephrine

c. Apply a warm compress to area

d. Apply a local anti-inflammatory cream to the site

b. Administer subcutaneous epinephrine

Injection of subcutaneous epinephrine should be given at the first sign of allergy.

p. 1967

Which person is most at risk for a hypersensitivity reaction?

a. 26-year-old receiving his second desensitization injection

b. 35-year-old starting back on birth control tablets

c. The 52-year-old started on a new series of Pyridium for cystitis

d. The 84-year-old receiving penicillin for an annually recurring respiratory infection

d. The 84-year-old receiving penicillin for an annually recurring respiratory infection

The 84-year-old with the deteriorated immune system is a prime candidate for a delayed hypersensitivity reaction.

p. 1960, Box 54-4

The nurse recommends to the busy mother of three that the antihistamine fexofenadine (Allegra) would be more beneficial than diphenhydramine (Benadryl) because Allegra:

a. is inexpensive.

b. contains a stimulant for an energy boost.

c. does not dry out the mucous membranes.

d. does not induce drowsiness.

d. does not induce drowsiness.

Allegra does not induce drowsiness as does Benadryl.

p. 1969

The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutaneous injection of epinephrine. What effect should the nurse assure the anxious patient this will have?

a. Cause vasodilation

b. Produce bronchodilation

c. Cause productive coughing

d. Reduction of pulse rate

b. Produce bronchodilation

The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces bronchodilation and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 20 minutes. The patient may experience an increase in heart rate.

p. 1970

Health care facilities have reduced the incidence of serious latex reactions by:

a. Having local and injectable corticosteroids on hand for employees

b. Desensitizing staff who are allergic

c. Supplying extra handwashing stations in the halls

d. Using only powder-free gloves

d. Using only powder-free gloves

Powder inside gloves can become aerosolized and cause inhalant reactions.

p. 1971

What should the nurse include to assess for in the plan of care for a patient undergoing plasmapheresis?

a. Hypotension

b. Hypersensitivity

c. Urticaria

d. Flank pain

a. Hypotension

Hypotension occurs during plasmapheresis because of transient volume changes in the blood.

p. 1975

A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, what should the patient receive?

a. Larger doses each week

b. Higher concentrations each week

c. Increased amounts and concentrations in 6-week cycles

d. The same amount and concentration each visit

c. Increased amounts and concentrations in 6-week cycles

Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period.

p. 1967

What is the term for transplantation of tissue between members of the same species?

a. Allograft

b. Autograft

c. Isograft

d. Homograft

a. Allograft

The allograft is the transplantation of tissues between members of the same species, such as a graft for full-thickness burns.

p. 1973

In which patient should the nurse be most concerned about immunodeficiency disorder?

a. The patient taking desensitization injections (immunotherapy)

b. The patient on long-term radiation therapy for cancer

c. The overweight patient

d. The patient recently diagnosed with lupus erythematosus

b. The patient on long-term radiation therapy for cancer

Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone marrow.

p. 1974

What is the purpose of plasmapheresis in the treatment of rheumatoid arthritis?

a. To add corticosteroids to relieve pain

b. To remove pathologic substances present in the plasma

c. To remove waste products such as urea and albumin

d. To add antinuclear antibodies

b. To remove pathologic substances present in the plasma

Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease.

p. 1974

The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient received a ___________ type of immunity.

a. Active natural

b. Passive natural

c. Active artificial

d. Passive artificial

d. Passive artificial

When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is considered a passive artificial immunity.

p. 1960, Box 54-1

Because the older adult has decreased production of saliva and gastric secretions, they are at risk for:

a. mouth ulcers.

b. fissures in corners of the mouth.

c. gastrointestinal infections.

d. bloating.

c. gastrointestinal infections.

Deficient saliva and gastric secretions make the older adult prone to gastrointestinal infections.

p. 1968

What is the major negative effect of cell-mediated immunity?

a. Depression of bone marrow

b. Rejection of transplanted tissue

c. Activation of the T cells

d. Stimulation of the B cells

b. Rejection of transplanted tissue

Cell-mediated immunity has the negative effect of rejection of transplanted tissue. Activation of T cells and stimulation of B cells are the positive basis of the cell-mediated immunity.

p. 1965

What is B-cell proliferation dependent on?

a. Presence of NK (natural killer) cells

b. Complement system

c. Antigen stimulation

d. Lymphokines

c. Antigen stimulation

Antigen stimulation is the sole focus of B-cell proliferation.

p. 1964

What timeframe must blood be transfused within once it has been removed from refrigeration?

a. 2 hours

b. 4 hours

c. 6 hours

d. 3 hours

b. 4 hours

Blood must be administered within 4 hours after removal from refrigeration, and blood components within 6 hours of removal.

p. 1972

The LPN/LVN has arrived at the patient's bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do?

a. Check to ensure that the donor and recipient numbers match according to policy

b. Request the patient to sign the card on the packed cells

c. Immediately administer the packed cells

d. Check the patient's ID bracelet and then administer the packed cells

a. Check to ensure that the donor and recipient numbers match according to policy

Donor and recipient numbers are specific and must be thoroughly checked and the patient identified with an armband.

p. 1972

The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What should be the nurse's initial action?

a. Cover with a warm blanket

b. Take the patient's temperature

c. Elevate the head of the bed

d. Stop the transfusion and continue with saline

d. Stop the transfusion and continue with saline

Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, and cough The initial intervention should be to stop the transfusion and continue with saline. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance at this time.

p. 1972

Which symptom would be classified as a mild transfusion reaction?

a. Orthopnea

b. Tachycardia

c. Hypotension

d. Wheezing

a. Orthopnea

Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea.

p. 1972

What should the nurse do because of the increasing strength of the dose in the injections for immunotherapy?

a. Observe the patient for at least 20 minutes after administration

b. Take the vital signs every 10 minutes for an hour

c. Have the patient lie down quietly for an hour

d. Place a warm compress on the area to speed its absorption

a. Observe the patient for at least 20 minutes after administration

The patient should be observed for 20 minutes after the increased dose of the allergen. If anaphylaxis is going to occur, it will do so within that time frame.

p. 1967

If a nurse is sensitive to latex gloves, what potential food sensitivities might the nurse develop? (Select all that apply.)

a. Peanuts

b. Avocados

c. Milk

d. Bananas

e. Tomatoes

f. Potatoes

b. Avocados

d. Bananas

e. Tomatoes

f. Potatoes

A person sensitive to latex may also be sensitive to certain foods, including avocados, kiwi, guava, bananas, water chestnuts, hazelnuts, tomatoes, potatoes, peaches, grapes, and apricots.

p. 1971

Which of the following provide the body with innate immunity? (Select all that apply.)

a. Skin and mucous membranes

b. Lungs

c. Heart

d. Tears and saliva

e. Natural intestinal and vaginal flora

f. Stomach acid

a. Skin and mucous membranes

d. Tears and saliva

e. Natural intestinal and vaginal flora

f. Stomach acid

The innate immune system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease.

p. 1963, Table 54-1

Which of the following are diseases which result from one's own immune system attacking the body? (Select all that apply.)

a. Lupus erythematosus

b. Glomerulonephritis

c. Polio

d. Rheumatoid arthritis

e. Thrombocytopenic purpura

f. Osteoarthritis

a. Lupus erythematosus

b. Glomerulonephritis

d. Rheumatoid arthritis

e. Thrombocytopenic purpura

Autoimmune diseases such as systemic lupus erythematosus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and Guillain-Barré syndrome are treated with plasmapheresis.

p. 1974

The nurse outlines the functions of the immune system as those actions which: (Select all that apply.)

a. Prevention of hemorrhage

b. Protection of the body's internal environment

c. Maintenance of hemoglobin level

d. Maintenance of homeostasis by removing damaged cells

e. Destruction of growth of abnormal cells

b. Protection of the body's internal environment

d. Maintenance of homeostasis by removing damaged cells

e. Destruction of growth of abnormal cells

The three main functions of the immune system are to protect the body's internal environment by destroying antigens and pathogens, maintenance of homeostasis by removing damaged cells, and the destruction of abnormal growth in the body.

p. 1962

To provide examples of an active acquired immunity, the nurse uses the example of a person who has acquired immunity from measles because that person has had: (Select all that apply.)

a. Chickenpox and mumps

b. Measles

c. An extremely healthy immune system

d. An inoculation against measles

e. Maternal antibodies against measles

b. Measles

d. An inoculation against measles

Active or acquired or adaptive immunity occurs from having had disease or having had an immunization against that specific disease.

p. 1963 Table 54-1

What is humoral immunity based on? (Select all that apply.)

a. Production of antibodies by B cells

b. T cells are activated by an antigen

c. The body's response to an antigen

d. Sensitized T cells destroy the antigen

e. Helper T cells activate phagocytosis

a. Production of antibodies by B cells

c. The body's response to an antigen

e. Helper T cells activate phagocytosis

Both types of immunity are in response to an antigen, In the humoral response helper T cells activate phagocytosis and the production of antibodies by the B cells. B cells are the main player in humoral response.

p. 1965

The nurse stresses that when a person produces his own antibodies against a specific antigen, that process of immunity is ______________ ________________ immunity

active acquired

When a person's immune system produces specific antibodies against an antigen, that process is an active acquired immunity.

p. 1964

A type IV latex allergy is characterized by________ _______.

contact dermatitis

Type IV latex allergy is that of a contact dermatitis.

p. 1971

The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is _______________

immunization

The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is immunization.

pp. 1966-1967

A transfusion using blood from one's own blood is a(n) ___________ transfusion, which is the best defense against a transfusion reaction

autologous

An autologous transfusion uses blood from one's own body.

p. 1973

The transfer of tissue between genetically identical individual (twins) is a(n) ________

isograft

An isograft is the transfer of tissue between genetically identical individual (twins).

p. 1973

The nurse outlines for a patient who has asthma attacks from pollen that the process from exposure to symptoms follows a systematic sequence. Place the physiologic responses of an allergic asthma attack in sequence. (Separate letters by a comma and space as follows: A, B, C, D)

a. Release of histamine

b. Edema

c. Vasodilation

d. Activation of mast cells

e. Bronchospasm

f. Exposure to pollen

f. Exposure to pollen

d. Activation of mast cells

a. Release of histamine

c. Vasodilation

b. Edema

e. Bronchospasm

F, D, A, C, B, E

The mast cells in the lungs are activated by the exposure to pollen. Histamine is released causing vasodilation, edema, and bronchospasm for the asthmatic.

p. 1968

List the sequence of a plasmapheresis procedure. (Separate letters by a comma and space as follows: A, B, C, D)

a. Removal of whole blood in one arm

b. Circulation of blood through cell separator

c. Remainder of plasma returned through vein in opposite arm

d. Separation of plasma and its cellular components

e. Replacement of plasma with lactated Ringer

f. Removal of undesirable components

a. Removal of whole blood in one arm

b. Circulation of blood through cell separator

d. Separation of plasma and its cellular components

f. Removal of undesirable components

c. Remainder of plasma returned through vein in opposite arm

e. Replacement of plasma with lactated Ringer

A, B, D, F, C, E

The whole blood is drawn out of one arm; circulated through a cell separator; plasma is separated with its cellular components; the undesirable components are removed; the remainder of plasma is returned through a vein in the opposite arm; and the lost plasma is replaced with lactated Ringer, normal saline, frozen plasma, or albumin.

p. 1974