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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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3
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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
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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