ch 31

A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of:

lymphocytes

During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses:

acquired immunity.

A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization, which will allow for the release of which type of substance?

Antibodies

An infection control nurse is presenting an in-service reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining?

Agglutination

A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will cause the client to develop which expected and desired condition?

Passive acquired immunity

A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which complication of therapy?

Immunosuppression

A nurse is planning the assessment of a client who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among which group?

Women

A client has been brought to the emergency department by the parents after falling through the glass of a patio door, sustaining a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of which type of cell?

Phagocytic cells

A client was scratched by an old tool and developed a virulent staphylococcus infection. During the immune response, circulating lymphocytes containing the antigenic message returned to the nearest lymph node. During what stage of the immune response did this occur?

Proliferation stage

A client with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. Which immune response predominates in this situation?

Cellular

A client being treated for bacterial pneumonia initially experienced dyspnea and a high fever but now claims to be feeling better and is afebrile. The client is most likely in which stage of the immune response?

Effector stage

The nurse is providing care for a client who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment?

Stem cell transplantation

A client's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at this client's site of inflammation?

Neutrophils

A nurse is planning a client's care and is relating it to normal immune response. During which stage of the immune response do sensitized lymphocytes stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate?

Proliferation stage

The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following?

Spleen

A client with hepatitis B has been admitted to the medical intensive care unit with sepsis. Which immunity function was most likely compromised?

Complement system

A nurse has admitted a client who has been diagnosed with urosepsis. Which immune response predominates in sepsis?

Humoral

A nurse is reviewing a client's medication administration record in an effort to identify drugs that may contribute to the client's recent immunosuppression. What drug is most likely to have this effect?

An antineoplastic

A client requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this client most likely has which type of immune disorder?

A primary immune deficiency

A neonate exhibited some preliminary signs of infection, but the infant's condition resolved spontaneously prior to discharge home from the hospital. This infant's recovery was most likely due to which type of immunity?

Nonspecific immunity

A gerontologic nurse is caring for a 78-year-old client who has a diagnosis of pneumonia. Which age-related change increases older adults' susceptibility to respiratory infections?

Impaired ciliary action

A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process?

Apoptosis

A client is responding to a microbial invasion and the client's differentiated lymphocytes have begun to function in either a humoral or a cellular capacity. During what stage of the immune response does this occur?

The response stage

A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response?

Antibodies are made by B lymphocytes in response to a specific antigen.

A client is undergoing testing to determine the overall function of the client’s immune system. Which test will best identify the functioning of the client's cellular immune system?

Delayed hypersensitivity skin test

Diagnostic testing has revealed a deficiency in the function of a client's complement system. This client is likely to have an impaired ability to do what action?

Bridge natural and acquired immunity.

A client's current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by which cells?

Cytotoxic T cells

A nurse is explaining how the humoral and cellular immune responses should be seen as interacting parts of the broader immune system rather than as independent and unrelated processes. What aspect of immune function best demonstrates this?

The interactions that occur between T cells and B cells

A nurse is caring for a client who has had a severe antigen–antibody reaction. Which portion of the antigen is involved in binding with the antibody?

Antigenic determinant

A client is being treated for cancer, and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which way?

Depressing antibody response

A client is vigilant in self-care but is frustrated by a recent history of upper respiratory infections and influenza. Which aspects of the client's lifestyle may have a negative effect on immune response? Select all that apply.

A. Exercises at the gym twice a day

B. Does not consume any red meat

C. Takes over-the-counter daily vitamins

D. Sleeps approximately seven hours daily

E. Works as a medical researcher

Exercises at the gym twice a day, Works as a medical researcher

A nurse educator is developing a care plan concerning a risk of infection related to vascular insufficiency. Which disease and/or injury would most likely align with this nursing care plan?

Diabetes

The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

Palpation of the client's lymph nodes

A client's exposure to which microorganism is most likely to trigger a cellular response?

Herpes simplex

A client was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response?

Proliferation

A client's natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances natural immunity?

Gastric secretions

A client is fighting an active infection. What function will cytokines perform in this immune response?

Determining whether the immune response will be the production of antibodies or a cell-mediated response

A client has undergone treatment for urosepsis and received high doses of numerous antibiotics during the course of treatment. When planning the client's subsequent care, the nurse should be aware of which potential effect on the client's immune function?

Bone marrow suppression

A client's recent diagnostic testing included a total lymphocyte count. The results of this test will allow the care team to gauge what aspect of the client's immunity?

Cell-mediated immune function