CH 19 - Inflammation and the Immune Response

Question 1

B. The ability to recognize self versus non-self is necessary to prevent healthy body cells from being destroyed along with the invaders. This meets the client’s protection needs.

Answer 1

The client who is exposed to invaders recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client?
A. Intact skin and mucous membranes
B. Self-tolerance
C. Inflammatory response against invading foreign proteins
D. Antibody-antigen interaction

Question 2

A. Inflammation is the process that occurs in response to invasion by organisms. In otitis media, it is a bacterium.

Answer 2

Which statement accurately explains otitis media?
A. The inflammatory response is triggered by the invasion of foreign proteins.
B. Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders.
C. It is caused by a left shift or increase in immature neutrophils.
D. Many immune system cells released into the blood have specific effects.

Question 3

D. The normal count for basophils (baso) is 0.5%. An elevated count indicates inflammation, which is common with chronic sinusitis.

Answer 3

A complete blood count with differential is performed in the client with chronic sinusitis. Which finding does the nurse expect?
A. Segmented neutrophils, 62%
B. Lymphocytes, 28%
C. Bands, 5%
D. Basophils, 4%

Question 4

A. : Instruction on increased signs and symptoms of inflammation could reveal signs of potential infection.

Answer 4

The nurse is preparing the client for discharge on postoperative day 1after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client’s discharge plan?
A. “Please report any increased redness, swelling, warmth, pain, or lack of movement to your health care provider.”
B. “Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed.”
C. “A referral has been made to the American Cancer Society’s Reach to Recovery program, and a volunteer will call you next week.”
D. “Avoid the prone and hunched-back positions, and ask your health care provider for any other needed activity restrictions.”

Question 5

B. This client is ready for discharge. CBC is within normal limits.

Answer 5

Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner?
A. Older adult client with a history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 15.5, segs 8.0, bands 5, lungs with slight crackles in bases, able to assist with activities of daily living (ADLs), and afebrile
B. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, white blood cell count (WBC) 9.5, segs 6.0, bands 1.0, oxygen saturation of 93% on room air, and afebrile
C. Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, white blood cell count (WBC) 20.0, segs 7.0, bands 10.0, oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4° F (38° C)
D. Older adult client with recent history of right hip replacement, with productive cough, white blood cell count (WBC) 3.4, segs 6.2, bands 5, lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile

Question 6

D. Optimal function of CMI requires a balance between helper and inducer T-cells and suppressor T-cells. This balance occurs when helper and inducer T-cells outnumber suppressor T-cells by a ratio of 2:1.

Answer 6

Which statement best exemplifies the client’s protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos?
A. Cytotoxic and cytolytic T-cells destroy cells that contain the major histocompatibility complex of a processed antigen.
B. Helper and inducer T-cells recognize self-cells versus non-self-cells and secrete lymphokines that can enhance the activity of white blood cells.
C. Suppressor T-cells prevent hypersensitivity when a client is exposed to non-self-cells or to proteins.
D. Balance elicits protection when helper or inducer T-cells outnumber suppressor T-cells by a ratio of 2:1.

Question 7

B. Multiple pregnancies and blood transfusions greatly increase the risk of a hyperacute rejection.

Answer 7

Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection?
A. Older adult with Parkinson disease receiving a donation from an identical twin
B. Grand multipara female with a history of subsequent blood transfusions
C. Middle-aged man with a 20-pack-year history
D. Young adult with type 1 diabetes

Question 8

C. Blood sugar is not affected by taking cyclosporine.

Answer 8

The nurse is teaching the client about cyclosporine (Sandimmune) therapy after a liver transplantation. Which client statement indicates the need for further teaching?
A. “I will be on this medicine for the rest of my life.”
B. “I must undergo regular kidney function tests.”
C. “I must regularly monitor my blood sugar.”
D. “My gums may become swollen because of this drug.”

Question 9

D. This nurse has experience and understanding of the needs of a post-transplantation client and knowledge of the drug.

Answer 9

Which of these home health nurses should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)?
A. An RN who has worked for the home health agency for 5 years in maternal-child health
B. An RN who has extensive critical care nursing experience and has worked in home health for a year
C. An RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit
D. An RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency

Question 10

B. This care can be delegated to the home health aide.

Answer 10

Which of these nursing activities can the nurse delegate to a home health aide?
A. Changing the dressing for a client with a low absolute neutrophil count
B. Assisting with bathing for a client with chronic rejection of a liver transplant
C. Teaching a client with bacterial pneumonia how to take the prescribed antibiotic
D. Assessing incisional tenderness for a client who had a recent kidney transplant

Question 11

B. Eosinophils have granules that contain enzymes to degrade histamine and other vasoactive amines and thereby limit allergic and inflammatory responses. Normally, eosinophils compose only 1% to 2% of the total white blood cell population. This value rises in response to an allergic reaction of any type.

Answer 11

A client’s complete blood count (CBC) with differential has the following values. Which value indicates to the nurse that the client is having some type of allergic reaction?
A. Total white blood cell (WBC) count 100%
B. Eosinophils 11%
C. Lymphocytes 38%
D. Neutrophils 66%

Question 12

B. The client should be taught all of these precautions. However, because anyone who is immunosuppressed is unable to adequately defend against an infection, even a minor infection has the potential to lead to life-threatening sepsis. No infection, no matter how minor, should be ignored in a client who is immunosuppressed. 

Answer 12

Which precaution is most important for the nurse to teach a client receiving long-term immunosuppressive therapy for an autoimmune disease?
A. Avoid crowds and people who are ill.
B. Call your health care provider at the first sign of an infection.
C. Assess your response to this medication at least once per month.
D. Be sure to tell your dentist you are taking this therapy before having any dental work.

Question 13

A. The clinical record should have all known hypersensitivities listed for the client. Also, ask the client about any known allergies.

Answer 13

The client recently admitted to the hospital is to receive an antibiotic intravenously for the first time for a urinary tract infection. Before checking the five R’s prior to administration, what is the nurse’s first action?
A. Review the clinical records and ask the client about any known allergies.
B. Check with the pharmacy for any known allergies for this client.
C. Check the client’s identification band for any allergies.
D. Ask the nurse who previously cared for the client about any known allergies.

Question 14

C. Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins. Avoidance therapy is the recommended nursing intervention. 

Answer 14

Assessment findings reveal that the client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client?
A. Report the need for desensitization therapy.
B. Convey the need for pharmacologic therapy to the health care provider.
C. Communicate the need for avoidance therapy to the health care team.
D. Discuss symptomatic therapy with the health care provider.

Question 15

A,C,D: Arthralgia (achy joints), Lymphadenopathy (enlarged lymph nodes), Malaise are symptoms of serum sickness.

Answer 15

The nurse is assessing a client with suspected serum sickness. Which symptoms will be consistent with serum sickness? Select all that apply.
A. Arthralgia
B. Blurred vision
C. Lymphadenopathy
D. Malaise
E. Ptosis

Question 16

D. No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe. This statement indicates more teaching is needed 

Answer 16

The nurse is reviewing discharge teaching with the client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching?
A. “I must wear a medical alert bracelet stating that I am allergic to bee stings.”
B. “I need to carry epinephrine with me.”
C. “My spouse must learn how to give me an injection.”
D. “I am immune to bee stings now that I have had a reaction.”

Question 17

C. Removing cloth drapes, carpet, and upholstery will reduce airborne pollen, dust mites, and mold.

Answer 17

The client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client’s discharge teaching plan?
A. Wash fruits and vegetables with mild soap and water before eating.
B. Intermittent exposure to known allergens will produce immunity.
C. Remove cloth drapes, carpeting, and upholstered furniture.
D. Be cautious when eating unprocessed honey.

Question 18

A. Antihistamines and corticosteroid inhalers should be discontinued before skin testing to avoid suppressing an allergic response.

Answer 18

When preparing the client for allergy testing, the nurse provides the client with which instruction?
A. “Avoid taking your loratadine (Claritin) and triamcinolone (Azmacort) inhaler for 5 days before testing.”
B. “It is okay to use your fluticasone propionate (Flonase) nasal spray before testing.”
C. “Aspirin in a low dose is allowed to be taken before testing.”
D. “You can take antihistamine nasal sprays before testing.”

Question 19

B. This is a delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity).

Answer 19

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity?
A. “It is a reaction of immune globulin (Ig)G with the host cell membrane or antigen.”
B. “The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation.”
C. “It results in release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells.”
D. “An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels.”

Question 20

D. Zafirlukast is a leukotriene antagonist that prevents the occurrence of allergic rhinitis by blocking the leukotriene receptor. 

Answer 20

The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. The nurse understands that zafirlukast works by which mechanism?
A. Blocking histamine from binding to receptors
B. Preventing synthesis of mediators
C. Preventing mast cell membranes from opening
D. Blocking the leukotriene receptor

Question 21

C. Allergic asthma is a manifestation of type I hypersensitivity.

Answer 21

The nurse plans to assess the client with type I hypersensitivity for which clinical manifestation?
A. Poison ivy
B. Autoimmune hemolytic anemia
C. Allergic asthma
D. Rheumatoid arthritis

Question 22

D. Oxygen application helps to provide adequate oxygenation for the client who is in respiratory distress.

Answer 22

The middle-aged client, who is alert, is admitted to the emergency department (ED) with wheezing, difficulty breathing, angioedema, blood pressure (BP) of 70/52, and apical pulse of 122 and irregular. The nurse makes an immediate assessment using the ABCs for any client experiencing anaphylaxis. What nursing intervention is the immediate priority?
A. Raise the lower extremities.
B. Start intravenous (IV) administration of normal saline.
C. Reassure the client that appropriate interventions are being instituted.
D. Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.

Question 23

A. : The client is experiencing an anaphylactic reaction, and epinephrine is a first-line sympathomimetic used to treat anaphylaxis.

Answer 23

Situation: The client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation?
A. Epinephrine (Adrenalin)
B. Fexofenadine (Allegra)
C. Cromolyn sodium (Nasalcrom)
D. Zileuton (Zyflo)

Question 24

D. Zafirlukast (Accolate) is a leukotriene receptor antagonist; it works by blocking the leukotriene receptor and is used to prevent allergic rhinitis.

Answer 24

Situation: The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed?
A. Cromolyn sodium (Nasalcrom)
B. Desloratadine (Clarinex)
C. Fexofenadine (Allegra)
D. Zafirlukast (Accolate)

Question 25

A. Fluid retention
B. Gastric distress
D. Infection
E. Osteoporosis

Answer 25

A client is prescribed prednisone for treatment of a type I reaction. The nurse plans to monitor the client for which adverse effects? Select all that apply.
A. Fluid retention
B. Gastric distress
C. Hypotension
D. Infection
E. Osteoporosis

Question 26

C. Because the antibiotic is the most likely cause of the client’s anaphylactic reaction, the nurse’s first action should be to discontinue the antibiotic.

Answer 26

A client who is receiving an intravenous antibiotic begins to cough and states, “My throat feels like it is swelling.” Which action will the nurse take next?
A. Infuse normal saline at 200 mL/hr.
B. Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously.
C. Discontinue infusing the antibiotic.
D. Give diphenhydramine (Benadryl) 100 mg IV.

Question 27

D. Reminding a client about safety policies is within the scope of practice of a nursing assistant.

Answer 27

Which of these nursing actions is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant?
A. Plan the schedule for desensitization therapy for a client with allergies.
B. Monitor the client who has just received skin testing for signs of anaphylaxis.
C. Educate a client with a latex allergy about other substances with cross-sensitivity to latex.
D. Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.

Question 28

D. Decongestants have actions similar to adrenergic drugs, causing vasoconstriction, which can increase blood pressure.

Answer 28

The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client's health care provider if the client has which condition?
A. Cataracts
B. Crohn's disease
C. Diabetes mellitus
D. Hypertension

Question 29

D. Stridor indicates airway involvement and warrants immediate intervention such as use of oxygen and administration of epinephrine. Maintaining the client’s airway is the high-test priority. 

Answer 29

A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse?
A. Anxiousness
B. Urticaria
C. Pruritus
D. Stridor

Question 30

B. Norepinephrine (Levophed) is a vasopressor and can cause headache.

Answer 30

A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effects?
A. Bradycardia
B. Headache
C. Infection
D. Metabolic alkalosis

Question 31

B. Hemoptysis is a manifestation of Goodpasture’s syndrome. Goodpasture’s syndrome usually is not diagnosed until serious lung and kidney problems are present. 

Answer 31

A client is admitted to the hospital with suspected Goodpasture's syndrome. Which findings will the nurse expect to observe?
A. Bradycardia
B. Hemoptysis
C. Increased urine output
D. Weight loss