Chapter 18: Assessment of Immune Function MULTIPLE CHOICE 1. The nurse is teaching a group of patients about first-line defense against infection. Which patient statement indicates the need for further education? 1. “The skin is a first-line defense against infection.” 2. “A sneeze is a mechanical first-line defense against infection.” 3. “My saliva is a biochemical first-line defense against infection.” 4. “A cut with pus is a mechanical first-line defense against infection.” ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 1. Identifying key anatomical components of the immune system Chapter page reference: 340 Heading: Introduction Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Inflammation Difficulty: Difficult Feedback 1 2 3 4 This statement indicates correct understanding of first-line defenses against infection. This statement indicates correct understanding of first-line defenses against infection. This statement indicates correct understanding of first-line defenses against infection. Pus or exudate indicates cellular infiltration which is a second line of defense against infection. This second line of defense is an inflammatory response to acute cellular injury. PTS: 1 CON: Inflammation 2. The nurse correlates the function of the thymus gland to which outcome? 1. White blood cell development 2. T-cell development 3. Cytokine production 4. B-cell production ANS: 2 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 2. Discussing the function of the immune system Chapter page reference: 341 Heading: Thymus Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Inflammation Difficulty: Moderate Feedback 1 2 3 4 White blood cell development occurs in the bone marrow and lymph tissue. The thymus is the central lymphoid organ that produces thymosin (a hormone that stimulates T-cell production) and is where T-cell development takes place. T cells are formed in the bone marrow but migrate to the thymus to mature. Cytokines are produced in response to specific antigens, and production occurs predominantly by macrophages and lymphocytes in response to initiation of the inflammatory response. B cells are formed and mature in the bone marrow. PTS: 1 CON: Inflammation 3. A nurse is caring for a patient with who is experiencing leukocytosis. When providing care to this patient, which action by the nurse is the most appropriate? 1. Assessing for the source of infection 2. Assessing for bleeding and bruising 3. Placing the patient in reverse isolation precautions 4. Instructing the patient on the use of an electric razor and soft toothbrush ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 5. Explaining nursing consideration for diagnostic examinations to immune function Chapter page reference: 344 - 345 Heading: Leukocytes Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4 A patient with leukocytosis has a white blood cell (WBC) count that is elevated above normal (>10,000 mm3), which is an indication of infection. The appropriate action by the nurse is to assess the patient for a source of the infection. Instructing the patient on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a patient with decreased platelet levels, or thrombocytopenia. Placing the patient in reverse isolation precautions would be appropriate for the patient with neutropenia, a decrease in the number of neutrophils. Instructing the patient on the use of an electric razor and soft toothbrush and assessing for bleeding and bruising would be appropriate actions for a patient with decreased platelet levels, or thrombocytopenia. PTS: 1 CON: Immunity 4. Which type of leukocyte releases heparin as part of the inflammatory response? 1. Basophil 2. Eosinophil 3. Monocyte 4. Neutrophil ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 2. Discussing the function of the immune system Chapter page reference: 344 - 345 Heading: Leukocytes Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4 Basophils release heparin as an anticoagulant and histamine during the early inflammatory response. Eosinophils are phagocytes that destroy allergens and combat parasitic infections. Monocytes phagocytize and clean up debris at the site of inflammation. Neutrophils are phagocytes of early inflammation that destroy bacteria. PTS: 1 CON: Immunity 5. The nurse recognizes that which immunoglobulin (Ig) is a mediator in allergic responses? 1. IgA 2. IgD 3. IgE 4. IgG ANS: 3 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 2. Discussing the function of the immune system Chapter page reference: 345 Heading: Immunoglobulins/ Table 18.2 Immunoglobulins Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Moderate Feedback 1 Immunoglobulin A (IgA) is the dominant Ig found in secretory gland secretions 2 3 4 such as breast milk, sweat, saliva, mucus, and tears. IgD is located primarily on the surface of developing B lymphocytes and plays a role in B-cell activation. IgE is the least concentrated Ig and acts as a mediator of many common allergic responses. It also acts as a defender against parasitic infections. IgG is the most abundant of the immunoglobulins. It is transported across the placenta and is effective against bacteria, viruses, and other toxins. PTS: 1 CON: Immunity 6. The nurse correlates which type of immunoglobulin (Ig) as playing a role in an allergic reaction? 1. IgA 2. IgD 3. IgE 4. IgM ANS: 3 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 4. Correlating relevant diagnostic examinations to immune function Chapter page reference: 345 Heading: Immunoglobulins Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Inflammation Difficulty: Moderate Feedback 1 2 3 4 Immunoglobulin A (IgA) is found in secretory gland secretions, such as breast milk, sweat, saliva, tears, and mucus. It is not produced during an allergic reaction. IgD plays a role in B-cell activation and is not produced during an allergic reaction. IgE is acts as a mediator of many common allergic responses. IgM is the first antibody produced during the primary response to an antigen. PTS: 1 CON: Inflammation 7. The nurse is teaching a new mother the immune benefits of breastfeeding her newborn. The nurse bases this teaching on the understanding that which immunoglobulin (Ig) is passed from mother to newborn through breast milk? 1. IgA 2. IgD 3. IgE 4. IgG ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 2. Discussing the function of the immune system Chapter page reference: 345 Heading: Immunoglobulins/ Table 18.2 Immunoglobulins Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4 Immunoglobulin A (IgA) is passed from mother to newborn in breast milk and provides immunity to the newborn. IgD plays a role in B-cell activation but is not secreted in breast milk. IgE has a role in allergic reactions but is not secreted in breast milk. IgG is passed through the placenta during pregnancy and provides the newborn with some immunity during the first few months of life. PTS: 1 CON: Immunity 8. The nurse educates a patient on first-line anatomic barriers to infection. Which patient statement indicates to the nurse the need for further teaching? 1. “Vomiting is an anatomic barrier to infection.” 2. “Coughing is an anatomic barrier to infection.” 3. “My saliva is an anatomic barrier to infection.” 4. “My skin acts as an anatomic barrier to infection.” ANS: 3 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 2. Discussing the function of the immune system Chapter page reference: 346 Heading: Physical, Mechanical, and Biochemical Barriers Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 2 3 4 Vomiting is an anatomic barrier to infection; therefore, this patient statement indicates a correct understanding of the information presented. Coughing is an anatomic barrier to infection; therefore, this patient statement indicates a correct understanding of the information presented. Saliva is a biochemical, not anatomic, barrier to infection; therefore, this patient statement indicates a need for additional teaching. The skin is an anatomic barrier to infection; therefore, this patient statement indicates a correct understanding of the information presented. PTS: 1 CON: Infection 9. Which clinical manifestation noted during the patient’s assessment indicates the need to notify the healthcare provider? 1. Coughing and sneezing 2. Earwax noted in the left canal 3. Tear production in both eyes 4. Swelling and redness noted to ankle ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 5. Explaining nursing considerations for diagnostic studies relevant to immune function Chapter page reference: 346 Heading: Physical, Mechanical, and Biochemical Barriers Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Inflammation Difficulty: Moderate Feedback 1 2 3 4 Coughing and sneezing are first lines of defense. This data does not require healthcare provider notification. Earwax is a first line of defense. This data does not require healthcare provider notification. Tears are a first line of defense. This data does not require healthcare provider notification. The second line of defense includes an inflammatory response to acute injury. During this response, vasodilation (redness, heat) and vascular permeability (edema) occur. This finding should be reported to the healthcare provider because this patient will likely require further intervention. PTS: 1 CON: Inflammation 10. The nurse assesses a patient with a surgical wound infection. Which clinical manifestation leads the nurse to conclude that the patient is experiencing a system response to inflammation? 1. Pain 2. Fever 3. Edema 4. Drainage ANS: 2 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 2. Discussing the function of the immune system Chapter page reference: 346 - 347 Heading: Inflammatory Process/Figure 18.7 Acute Inflammatory Responses Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback 1 2 3 4 Pain is a sign of inflammation but not an indication of a systemic response. Fever is an indication that the patient is experiencing a systemic response during an acute inflammatory response. Edema is a sign of inflammation but not an indication of a systemic response. Drainage is a sign of inflammation but not an indication of a systemic response. PTS: 1 CON: Inflammation 11. The nurse recognizes which type of immunity as an example of passive immunity? 1. Immunity acquired based on exposure to an antigen 2. Immunity acquired to a newborn through the placenta 3. Immunity acquired from an immunization 4. Immunity acquired from an infection ANS: 2 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 2. Discussing the function of the immune system Chapter page reference: 346 - 347 Heading: Adaptive Immune Response Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy Feedback 1 2 3 4 This is an example of active immunity and develops when antibodies or T cells are produced either after natural exposure to an antigen during illness or infection or after immunization. Passive immunity happens when preformed antibodies or T lymphocytes are transferred from one individual to another. For example, a newborn acquires immunity from his or her mother through the placenta, or an individual can acquire immunity through transfusion of antibody-laden blood products. This is an example of active immunity and develops when antibodies or T cells are produced either after natural exposure to an antigen during illness or infection or after immunization. This is an example of active immunity and develops when antibodies or T cells are produced either after natural exposure to an antigen during illness or infection or after immunization. PTS: 1 CON: Immunity 12. In reviewing the laboratory results for a patient admitted with hepatic disease, the nurse correlates which results with an increased risk of infection? 1. 2. 3. 4. White blood cell (WBC) count 5.0 103/mm3 Neutrophils 30% Eosinophils 2% Monocytes 8% ANS: 2 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 4. Correlating relevant diagnostic examinations to immune function Chapter page reference: 349 -350 Heading: Assessment of Immune System: History/ Table 18.4 Immune System Infection Risk Factors Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Infection Difficulty: Difficult Feedback 1 This is a normal white blood cell count. Normal range is (4.5–11.1 103/mm3). 2 Neutrophils are decreased in hepatic disease, placing the patient at increased risk of infection. The normal neutrophil count is 6,300 or 40% to 70% of differential. This is a normal eosinophil count. Normal values are 250 or 1% to 3% of differential. This is a normal monocyte count. Normal values are 1,800 or 2% to 8% of differential. 3 4 PTS: 1 CON: Infection 13. The nurse correlates an increased risk of infection in a patient receiving radiation therapy for lung cancer based on which of the following factors? 1. Damage to second line of defense 2. Damage to first line of defense 3. Elevated white blood cell production 4. Decreased phagocytic action ANS: 2 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 1. Identifying key anatomical components of the immune system Chapter page reference: 349 - 350 Heading: Assessment of the Immune System/History/ Table 18.4 Immune System Infection Risk Factors Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Infection Difficulty: Moderate Feedback 1 2 3 4 The second line of defense is the inflammatory process. Radiation impacts the first line of defense by affecting skin integrity, which is a physical barrier. The first line of defense relies on anatomical and biochemical barriers for protection. Radiation therapy can damage skin which is part of this first line of defense. White blood cell production is decreased as a result of the radiation therapy’s impact on the bone marrow. Phagocytic action is related to the inflammatory response that is associated with the second line of defense. PTS: 1 CON: Infection 14. Which question does the nurse need to ask during a health history with an adolescent patient, accompanied by a parent, to determine immune status? 1. “Is your child sexually active?” 2. “Does your child get annual checkups?” 3. “Does your child smoke tobacco products?” 4. “Are your child’s immunizations up-to-date?” ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 349 - 350 Heading: Assessment of the Immune System: History Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Easy Feedback 1 2 3 4 Although sexual activity places the adolescent at risk for sexual transmitted infections, this is not the most appropriate question for the nurse to ask to determine immune status. Although asking about annual checkups is relevant, this is not as important as knowing about the current immunization status. Although smoking can increase the risk for infection, this is not an appropriate question for the nurse to ask an adolescent patient when a parent is in the room. Inquiring about the child’s immunization status is appropriate during the health history interview to determine immune status. PTS: 1 CON: Assessment 15. The nurse is conducting a health history for a patient. In assessing immune function, which question is best to ask related to risk factors in the patient’s social history? 1. “Do you smoke cigarettes?” 2. “Are your immunizations current and up-to-date?” 3. “What type of reaction do you have with an allergy flair?” 4. “Did you have your spleen removed after your car accident?” ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 349 Heading: Assessment of the Immune System: History/ Box 18.1 Comprehensive Patient History Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4 This question is appropriate to assess the patient’s social history. This question is appropriate to assess the patient’s immunization history. This question is appropriate to assess the patient’s current problem. This question is appropriate to assess the patient’s medical or surgical history. PTS: 1 CON: Immunity 16. Which laboratory value requires an intervention by the nurse for the patient scheduled for a positron emission tomography (PET) scan? 1. White blood cell (WBC) count 12.5 103/mm3 2. Platelet count 450 mm3 3. Serum sodium 148 mEq/L 4. Serum glucose 250 mg/dL ANS: 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 5. Explaining nursing considerations for diagnostic studies relevant to immune function Chapter page reference: 350 - 352 Heading: Diagnostic Studies/Table 18.5 Diagnostic Tests for Immune Function Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback 1 2 This is a mildly elevated white blood cell count but does not impact the positron emission tomography (PET) scan. This is a normal platelet count. 3 4 This is an elevated serum sodium and the patient may be dehydrated, but this is not a contraindication for a PET scan. For a PET scan, blood sugar must be less than 200 mg/dL. PTS: 1 CON: Assessment 17. The nurse monitors for which laboratory result in the patient with a history of chronic inflammation? 1. Decreased white blood cell count 2. Elevated red blood cell count 3. Elevated erythrocyte sedimentation rate (ESR) 4. Decreased platelet count ANS: 3 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 4. Correlating relevant diagnostic examinations to immune function Chapter page reference: 350 - 352 Heading: Diagnostic Studies/Table 18.5 Diagnostic Tests for Immune Function Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Inflammation Difficulty: Easy Feedback 1 2 3 4 The white blood cell (WBC) count increases with chronic inflammation. The red blood cell (RBC) count is not influenced by inflammation. Changes in RBC may be related to conditions affecting the bone marrow. Erythrocyte sedimentation rate (ESR) screens for the presence of the inflammatory process, and it increases with inflammation. A decreased platelet count is not impacted by immune status. A decreased platelet count places the patient at risk of bleeding. PTS: 1 CON: Inflammation 18. Which of the following statements from the patient related to a scheduled bone marrow aspiration indicates patient understanding of the procedure? 1. “I am glad this is not painful like a bone marrow biopsy.” 2. “I need to contact my provider if I have a lot of bleeding after I go home.” 3. “I will have to monitor for signs of infection after the procedure.” 4. “I am glad that I will be able to receive pain medications as needed.” ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 5. Explaining nursing considerations for diagnostic studies relevant to immune function Chapter page reference: 350 - 352 Heading: Diagnostic Studies/Table 18.5 Diagnostic Tests for Immune Function Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Assessment Difficulty: Moderate Feedback 1 2 3 4 Although a bone marrow aspiration may not be as painful as a biopsy, there is some discomfort associated with the removal of the bone marrow. It is important to prepare the patient for the procedure, including pain or discomfort and risk of bleeding or infection. It is important to prepare the patient for the procedure, including pain or discomfort and risk of bleeding or infection. It is important to prepare the patient for the procedure, including pain or discomfort and risk of bleeding or infection. PTS: 1 CON: Assessment 19. The nurse provides education to an older adult patient regarding age-related immune system changes. Which patient statement indicates the need for further teaching? 1. “I am at an increased risk for cancer because of my age.” 2. “I may experience a decreased production of autoantibodies as I age.” 3. “If I am exposed to a virus, my body’s immune response is less efficient.” 4. “If my body produces malignant cells, it likely does not destroy them as quickly now.” ANS: 2 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 6. Discussing changes in immune function associated with aging Chapter page reference: 353 Heading: Age-Related Changes Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 2 3 This patient statement indicates a correct understanding of the information presented. Older adult patients are at increased risk for producing malignant cells. This, coupled with the fact that the older adult cannot destroy malignant cells as quickly as a younger person, increases the risk for cancer. Older adult patients experience an increased production of autoantibodies, which increases the risk of autoimmune disease. This patient statement indicates a need for additional teaching. This is an accurate statement from the patient regarding age-related changes to the immune system. 4 This patient statement indicates a correct understanding of the information presented. Older adult patients are at increased risk for producing malignant cells. This, coupled with the fact that the older adult cannot destroy malignant cells as quickly as a younger person, increases the risk for cancer. PTS: 1 CON: Immunity 20. The nurse correlates the increased risk of autoimmune disorders in the older adult to which age-related change of the immune system? 1. Increased B-cell production 2. Increased autoantibodies production 3. Increased T-cell production 4. Increased phagocytic capacity ANS: 2 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 6. Discussing changes in immune function associated with aging Chapter page reference: 353 Heading: Age Related Changes Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4 B-cell production decreases with age and may result in diminished immune memory. Older adults have an increase in the production of autoantibodies, leading to autoimmune disorders. Autoimmune disorders such as polymyalgia rheumatica, rheumatoid arthritis, and systemic lupus erythematosus are examples of problems caused by increased autoantibody production. Older adults have a decline in T-cell production and function, not increased. There is decreased phagocytic capacity in the older adult as a result of decreased neutrophils. PTS: 1 CON: Immunity 21. A nurse working in the emergency department (ED) is providing care for a group of patients. Which patient demonstrates a decline in immune response that typically occurs with the aging process? 1. An 88-year-old with pneumonia who has a temperature of 99.5°F. 2. A 56-year-old who has an 8-mm induration at the site of a purified protein derivative (PPD) skin test 72 hours earlier. 3. A 58-year-old who reports redness and itching as a result of a rash from contact with poison ivy. 4. A 70-year-old who has swelling and redness at the incision from an open appendectomy. ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 6. Discussing changes in immune function associated with aging Chapter page reference: 353 Heading: Age-Related Changes/ Table 18.6 – Age-Related Changes in the Immune System Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis (Analyzing) Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4 The patient who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration. This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration. This patient is demonstrating an expected immune response as evidenced by redness, swelling, and induration. PTS: 1 CON: Immunity 22. The nurse recognizes which nutritional deficiency as often impacting an older adult patient’s ability to mount an immune response? 1. Proteins 2. Calcium 3. Potassium 4. Fats ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 6. Discussing changes in immune function associated with aging. Chapter page reference: 353 Heading: Age Related Changes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Moderate Feedback 1 Nutritional status is a critical component of immunocompetence. Cellular immunity, phagocyte activity, and complement ability are greatly impacted by 2 3 4 protein deficiencies. A calcium deficiency is more likely to impact bone health. A potassium deficiency is more likely to impact cardiovascular health. A fat deficiency does not impact a patient’s ability to mount an immune response. PTS: 1 CON: Immunity MULTIPLE RESPONSE 1. In providing care to patients with compromised immune function, it is important that the nurse understand types of immunity. Which of the following leads to acquired (adaptive) immunity? Select all that apply. 1. Biochemical barriers 2. Vaccinations 3. Infection 4. Mechanical barriers 5. Transfer of maternal antibodies ANS: 2, 3, 5 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 1. Identifying key anatomical components of the immune system Chapter page reference: 340 Heading: Introduction Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4 5 This is incorrect. Biochemical, mechanical, and physical barriers are first lines of defense. This is correct. Acquired (adaptive) immunity occurs by natural exposure, including infection; transfer of maternal antibodies; or artificial exposure, such as vaccination or infusion of immune serum globulin. This is correct. Acquired (adaptive) immunity occurs by natural exposure, including infection; transfer of maternal antibodies; or artificial exposure, such as vaccination or infusion of immune serum globulin. This is incorrect. Biochemical, mechanical, and physical barriers are first lines of defense. This is correct. Acquired (adaptive) immunity occurs by natural exposure, including infection; transfer of maternal antibodies; or artificial exposure, such as vaccination or infusion of immune serum globulin. PTS: 1 CON: Immunity 2. Which locations does the nurse include when discussing the storage and production of lymphocytes during an education session for novice nurses? Select all that apply. 1. Liver 2. Spleen 3. Thymus 4. Lymph nodes 5. Bone marrow ANS: 2, 3, 4, 5 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 1. Identifying key anatomical components of the immune system Chapter page reference: 344 - 345 Heading: Leukocytes/Lymphocytes Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Easy 1 2 3 4 5 Feedback This is incorrect. The liver does not store or produce lymphocytes. This is correct. Lymphocytes are formed in the bone marrow, are found in the lymph nodes, spleen, and thymus, and enter the bloodstream through the lymphatic system. This is correct. Lymphocytes are formed in the bone marrow, are found in the lymph nodes, spleen, and thymus, and enter the bloodstream through the lymphatic system. This is correct. Lymphocytes are formed in the bone marrow, are found in the lymph nodes, spleen, and thymus, and enter the bloodstream through the lymphatic system. This is correct. Lymphocytes are formed in the bone marrow, are found in the lymph nodes, spleen, and thymus, and enter the bloodstream through the lymphatic system. PTS: 1 CON: Immunity 3. The nurse is assessing a patient’s immune system. Which findings increase the patient’s risk for infection as a result of alterations in biochemical barriers? Select all that apply. 1. Dysphagia 2. Dry mouth 3. Nonintact skin 4. Urinary retention 5. Clogged tear duct ANS: 2, 5 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 1. Identifying key anatomical components of the immune system Chapter page reference: 346 Heading: Physical, Mechanical, and Biochemical Barriers Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate 1 2 3 4 5 Feedback This is incorrect. Swallowing is a mechanical, not biochemical, barrier to infection. This is correct. Saliva is a biochemical barrier to infection. A dry mouth increases the patient’s risk for infection. This is incorrect. Intact skin is a physical, not biochemical, barrier to infection. This is incorrect. Urination is a mechanical, not biochemical, barrier to infection. This is correct. Tears are a biochemical barrier to infection. A clogged tear duct increases this patient’s risk for infection. PTS: 1 CON: Assessment 4. The nurse is assessing a patient’s immune system. Which findings increase the patient’s risk for infection as a result of alterations in mechanical barriers? Select all that apply. 1. Dysphagia 2. Dry mouth 3. Nonintact skin 4. Urinary retention 5. Clogged tear duct ANS: 1, 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 1. Identifying key anatomical components of the immune system Chapter page reference: 346 Heading: Physical, Mechanical, and Biochemical Barriers Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate 1 2 3 4 Feedback This is correct. Swallowing is a mechanical barrier to infection. Dysphagia, or impaired swallowing, increases the patient’s risk for infection. This is incorrect. Saliva is a biochemical, not mechanical, barrier to infection. A dry mouth increases the patient’s risk for infection. This is incorrect. Intact skin is a physical, not mechanical, barrier to infection. Nonintact skin increases the patient’s risk for infection. This is correct. Urination is a mechanical barrier to infection. Urinary retention increases the risk for bacterial growth and infection. 5 This is incorrect. Tears are a biochemical, not mechanical, barrier to infection. A clogged tear duct increases this patient’s risk for infection. PTS: 1 CON: Assessment 5. The nurse is conducting a physical assessment for a patient with a compromised immune system. Which actions by the nurse are appropriate? Select all that apply. 1. Assessing general appearance 2. Evaluating extraocular eye movement (EOM) 3. Checking joint range of motion (ROM), including that of the spine 4. Inspecting the mucous membranes of the nose and mouth for color and condition 5. Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness ANS: 1, 3, 4, 5 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 349 Heading: Assessment of the Immune System: History/ Box 18.1 Comprehensive Patient History Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate 1 2 3 4 5 Feedback This is correct. The techniques of inspection and palpation are especially important in assessing a patient’s immune system: The nurse will assess the patient’s general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient’s range of motion (ROM), including that of the spine. This is incorrect. Assessment of extraocular eye movement (EOM) does provide information related to the immune system. EOMs provide data related to the muscles that control eye movement. This is correct. The techniques of inspection and palpation are especially important in assessing a patient’s immune system: The nurse will assess the patient’s general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that of the spine. This is correct. The techniques of inspection and palpation are especially important in assessing a patient’s immune system: The nurse will assess the patient’s general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that of the spine. This is correct. The techniques of inspection and palpation are especially important in assessing a patient’s immune system: The nurse will assess the patient’s general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the patient’s ROM, including that of the spine. PTS: 1 CON: Assessment 6. The nurse correlates which factors to immunosenescence? Select all that apply. 1. Increased risk of infection 2. Increased risk of hearing loss 3. Increased risk of cancer 4. Increased risk of autoimmune disorders 5. Increased hypersensitivity reactions ANS: 1, 3, 4 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 6. Discussing changes in immune function associated with aging Chapter page reference: 353 Heading: Age-Related Changes Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Immunity Difficulty: Moderate Feedback 1 2 3 4 5 This is correct. Immunosenescence refers to those changes that occur to the immune system with aging and their consequences, including increased infection risk, increased risk of malignancy, and increased autoimmune disorders. This is incorrect. Hearing loss is associated with aging but not with changes in the immune system. This is correct. Immunosenescence refers to those changes that occur to the immune system with aging and their consequences, including increased infection risk, increased risk of malignancy, and increased autoimmune disorders. This is correct. Immunosenescence refers to those changes that occur to the immune system with aging and their consequences, including increased infection risk, increased risk of malignancy, and increased autoimmune disorders. This is incorrect. A decrease in B-cell production and function and antigen-specific immunoglobulin activity may also occur in older adults, creating delayed hypersensitivity reactions. PTS: 1 CON: Immunity 7. The nurse educates a patient who is malnourished to increase foods that are considered complete protein sources to decrease the risk for infection. Which food choices indicate to the nurse the need for further teaching? Select all that apply. 1. Corn 2. 3. 4. 5. Milk Fish Eggs Chicken ANS: 1 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of a patient with impaired immune function Chapter page reference: 354 Heading: Safety Alert Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Knowledge [Remembering] Concept: Infection Difficulty: Easy 1 2 3 4 5 Feedback This is correct. This food choice indicates an incorrect understanding of the information presented and the need for further teaching. Vegetables, such as corn, are incomplete proteins because they do not contain all essential amino acids. Sources of plant proteins must be coupled to achieve all essential amino acids. A combination of corn and beans would reflect a complete protein. This is incorrect. This food choice indicates a correct understanding of the information presented. Complete proteins contain all essential amino acids. Most animal proteins, including meats, poultry, fish, dairy products, and eggs, are examples of complete proteins. This is incorrect. This food choice indicates a correct understanding of the information presented. Complete proteins contain all essential amino acids. Most animal proteins, including meats, poultry, fish, dairy products, and eggs, are examples of complete proteins. This is incorrect. This food choice indicates a correct understanding of the information presented. Complete proteins contain all essential amino acids. Most animal proteins, including meats, poultry, fish, dairy products, and eggs, are examples of complete proteins. This is incorrect. This food choice indicates a correct understanding of the information presented. Complete proteins contain all essential amino acids. Most animal proteins, including meats, poultry, fish, dairy products, and eggs, are examples of complete proteins. PTS: 1 CON: Infection ORDERED RESPONSE 1. In providing care to a patient with an acute inflammatory response, the nurse correlates the following physiological responses as part of this process. Place the physiological responses in order from earliest to latest. 1. Cellular injury 2. Increased blood flow to area 3. Phagocytes and antibodies to site 4. Vasodilation 5. Pathogenic invasion 6. Inflammatory reponse ANS: 5, 1, 6, 4, 2, 3 Chapter number and title: 18, Assessment of Immune Function Chapter learning objective: 2. Discussing the function of the immune system Chapter page reference: 18-14 (callout for Fig. 18.7) Heading: Inflammatory Response Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Inflammation Difficulty: Difficult Feedback: The acute inflammatory response begins with invasion by a pathogen that leads to cellular injury and the initiation of the inflammatory response. The inflammatory response leads to vasodilation that results in increased blood to the site of injury or invasion. The increased blood flow results in phagocytes and antibodies coming to the area, as well as erythema and warmth. PTS: 1 CON: Inflammation