Chapter 55 immune

Question 1

Which situation 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

Answer 1

ANS: C
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
without residual illness.

Question 2

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. Which action
will be the nurse’s first intervention?
a. Apply cool compresses to urticaria.
b. Provide oxygen per nonrebreathing mask.
c. Cover patient with a warm blanket.
d. Prepare for venipuncture for the delivery of IV medication.

Answer 2

ANS: B
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.

Question 3

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

Answer 3

ANS: D
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.

Question 4

A patient is admitted with a secondary immunodeficiency from chemotherapy. The nurse
expects the plan of care to focus on which aspect?
a. infection control.
b. supporting self-care.
c. nutritional education.
d. maintaining high fluid intake.

Answer 4

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

Question 5

The nurse takes into consideration that when the antigen and antibody react, the complement
system is activated. This results in which activity?
a. toughens the cell wall.
b. generates more T cells.
c. attracts phagocytes.
d. makes the antigen resistant.

Answer 5

c. attracts phagocytes.

Question 6

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.

Answer 6

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

Question 7

Which advice will the nurse provide for a 94-year-old 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 -carotene

Answer 7

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

Question 8

A patient who works in a plant nursery and has experienced 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 insectstings.”
d. “I will need to take maintenance doses of corticosteroids to prevent reactions to
further stings.”

Answer 8

ANS: D
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.

Question 9

Which substance is released by the T cells that stimulates the lymphocytes to attack an
inflammation?
a. Lymphokine
b. Epinephrine
c. B cells
d. Histamine

Answer 9

ANS: A
Lymphokines help attract macrophages to the site of the inflammation.

Question 10

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 antiinflammatory cream to the site.

Answer 10

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

Question 11

Which person is most at risk for having a reduced number of T-cells?
a. 26 year old receiving a 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

Answer 11

ANS: D
The 84 year old with the deteriorated immune system is at risk for having a reduced number
of T-cells.

Question 12

The nurse recommends to the busy parent of three young children that the antihistamine
fexofenadine would be more beneficial than diphenhydramine because fexofenadine has
which quality?
a. is inexpensive.
b. contains a stimulant for an energy boost.
c. does not dry out the mucous membranes.
d. does not induce drowsiness.

Answer 12

ANS: D
Allegra does not induce drowsiness as does Benadryl.

Question 13

The patient who had an asthma-like reaction to a desensitization shot was medicated with a
subcutaneous injection of epinephrine. For which effect will the nurse assure the anxious
patient this will have?
a. Cause vasodilation.
b. Produce bronchodilation.
c. Cause productive coughing.
d. Reduction of pulse rate.

Answer 13

ANS: B
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.

Question 14

Health care facilities have reduced the incidence of serious latex reactions by taking which
action?
a. having local and injectable corticosteroids on hand for employees.
b. desensitizing staff who are allergic.
c. supplying extra hand washing stations in the halls.
d. using only powder-free gloves.

Answer 14

ANS: D
Powder inside gloves can become aerosolized and cause inhalant reactions.

Question 15

The nurse will monitor for which adverse effect when caring for a patient undergoing
plasmapheresis?
a. Hypotension
b. Hypersensitivity
c. Urticaria
d. Flank pain

Answer 15

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

Question 16

A patient is undergoing immunotherapy on a perennial basis. With this form of treatment,
the patient receives treatment scheduled in which way?
a. Larger doses each week
b. Higher concentrations each week
c. Increased amounts and concentrations
d. The same amount and concentration each visit

Answer 16

ANS: C
Perennial therapy is most widely accepted, because it allows for a higher cumulative dose,
which produces a better effect. Perennial therapy begins with a diluted dose of the allergen
that is increased progressively each week.

Question 17

Which term is used to describe transplantation of tissue between members of the same
species?
a. Allograft
b. Autograft
c. Isograft
d. Homograft

Answer 17

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

Question 18

In which patient will 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

Answer 18

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

Question 19

For which purpose is plasmapheresis used 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.

Answer 19

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

Question 20

The nurse explains that when the patient received tetanus antitoxin with the antibodies in it,
the patient received whic h type of immunity?
a. active natural
b. passive natural
c. active artificial
d. passive artificial

Answer 20

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

Question 21

Because the older adult has decreased production of saliva and gastric secretions, they are at
risk for which problem?
a. mouth ulcers.
b. fissures in corners of the mouth.
c. gastrointestinal infections.
d. bloating.

Answer 21

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

Question 22

Which concern is a 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

Answer 22

ANS: B
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.

Question 23

What is B-cell proliferation dependent on?
a. Presence of NK (natural killer) cells
b. Complement system
c. Antigen stimulation
d. Lymphokines

Answer 23

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

Question 24

In which time frame must blood be transfused within once it has been removed from
refrigeration?
a. 2 hours
b. 4 hours
c. 6 hours
d. 3 hours

Answer 24

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

Question 25

The nurse has arrived at the patient’s bedside with a unit of packed cells to be connected to an IV that is infusing. When the registered nurse arrives, which action do the nurses take first? 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.

Answer 25

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

Question 26

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 will 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.

Answer 26

ANS: D Moderate reactions, resulting in fever, chills, urticaria, and wheezing, occur after the first 30 minutes of administration. In the event of a moderate reaction, stop the transfusion, continue with saline, and notify the health care provider. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance.

Question 27

Which symptom would be classified as a mild transfusion reaction? a. Orthopnea b. Tachycardia c. Hypotension d. Wheezing

Answer 27

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

Question 28

Which action will the nurse take when a patient is receiving 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.

Answer 28

ANS: A 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.

Question 29

The nurse outlines for a patient who has asthma attacks from pollen that the process from exposure to symptoms follows a systematic sequence. Which change is the last physiologic responses of an allergic asthma attack? a. Release of histamine b. Edema c. Vasodilation d. Activation of mast cells e. Bronchospasm f. Exposure to pollen

Answer 29

ANS: 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.

Question 30

Which step is the third step in the sequence of a plasmapheresis procedure? 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

Answer 30

ANS: D 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.