Immune

Question 1

A parent of a newborn asks the nurse why young children seem to become ill so often when
compared with older children and adults. Which is the best response by the nurse?
1. “Newborns have lower numbers of natural killer cells.”
2. “Newborns have high levels of IgA in their systems.”
3. “Newborns are lacking lymphoid tissue.”
4. “Newborns have an immature thymus gland.”

Answer 1

1. “Newborns have lower numbers of natural killer cells.”
   Explanation:
2. Newborns have lower numbers of natural killer cells than do older children and adults,
   decreasing their ability to respond to certain antigens.
3. IgA is not present at birth. Development of IgA begins at 2 weeks of age but does not
   reach adult levels until the age of 6.
4. Lymphoid tissue, such as the spleen and tonsils, is present at birth.
5. The thymus is large at birth and grows during childhood, decreasing by adulthood.

Question 2

A premature neonate is at greater risk for infection than a full-term newborn because of a
reduced number of which immunoglobulin?
1. IgE
2. IgG
3. IgA
4. IgM

Answer 2

2. IgG
   Explanation:
3. IgE does not cross the placenta and is not present at birth in either preterm or full-term
   infants.
4. Maternal IgG crosses the placenta. Newborns’ levels are similar to their mothers’.
   Premature infants have lower levels of IgG obtained from their mothers and are at
   greater risk for infection.
5. IgA does not cross the placenta and is not present at birth in either preterm or full-term
   infants.
6. IgM does not cross the placenta. The levels are low at birth in both preterm and full-
   term infants.

Question 3

The nurse is planning care for a child with acquired immune deficiency syndrome (AIDS).
Which vaccines should be avoided in the child with AIDS?
1. Inactivated polio vaccine
2. Tetanus toxoid vaccination
3. Varicella vaccine
4. Acellular pertussis vaccine

Answer 3

3. Varicella vaccine
   Explanation:
4. Killed virus vaccines are safe to administer to the child with AIDS as there is no risk of
   acquiring an infection.
5. A toxoid vaccination is made of a toxin that has been produced by the organism but
   does not include living organisms.
6. A child with an immune disorder should not be immunized with a live varicella vaccine
   because of the risk of contracting the disease.
7. Acellular pertussis vaccine contains a protein from pertussis rather than the whole cell.

Question 4

An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which
action by the client indicates acceptance of the body changes that occur because of SLE?
1. Attends school but does not stay for after-school activities
2. Discusses the body changes with healthcare providers only
3. Discusses the body changes with her best friend
4. Only attends small parties at friends’ homes

Answer 4

3. Discuss the body changes with her best friend.
   Explanation:
4. Avoiding social activities does not show acceptance of body changes.
5. Discussing changes only with healthcare providers does not indicate the teen has
   adjusted to the body image changes.
6. Peer interaction is important to the teen. Being able to discuss the changes to her body
   with a peer indicates acceptance of the changes in her body image.
7. Avoiding social activities other than those involving immediate friends indicates the
   teen is still concerned with body image.

Question 5

A school-age client diagnosed with rheumatoid arthritis (RA) wants to participate in the
school sports programs. The client asks the nurse to recommend a sporting activity that is
appropriate. Which activity would be the most appropriate for the nurse to recommend?
1. Baseball
2. Basketball
3. Football
4. Swimming

Answer 5

4. Swimming
   Explanation:
5. Baseball places stress on the knee joints.
6. Basketball involves running, which will stress the joints.
7. All positions in football will cause stress to the joints.
8. Swimming helps to exercise all the extremities without putting undue stress on joints.

Question 6

The nurse is caring for a child with rheumatoid arthritis. Which nonpharmacologic
intervention should the nurse include in the plan of care for joint pain?
1. Elevation of the extremity
2. Immobilization
3. Massage
4. Application of moist heat

Answer 6

4. Application of moist heat
   Explanation:
5. Elevation of the extremity would not have an effect on reducing pain in rheumatoid
   arthritis.
6. Immobilization can lead to contractures. Range of motion to the involved joint should
   be maintained.
7. Massage of extremities should be avoided because of potential risk for emboli.
8. Moist heat can promote relief of pain and decrease joint stiffness.

Question 7

In which position should the nurse place a child who is experiencing an anaphylactic shock
reaction?
1. Trendelenburg position
2. Flat, with legs slightly elevated
3. High Fowler position
4. Reverse Trendelenburg position

Answer 7

2. Flat, with legs slightly elevated
   Explanation:
3. The Trendelenburg position has the head of the bed lowered and is no longer
   recommended for the treatment of shock, as it causes abdominal organs to press against
   the diaphragm, which impedes respirations and decreases coronary artery filling.
4. Flat, with legs slightly elevated, is the position that is used for a client experiencing
   shock. This allows for the blood pressure to be maintained during this critical time.
5. The high Fowler position has the head of the bed elevated and will not be effective to
   maintain a blood pressure when shock is occurring.
6. The reverse Trendelenburg position has the head of the bed elevated and will not be
   effective to maintain a blood pressure when shock is occurring.

Question 8

A child is prescribed oral corticosteroid for a rash caused by graft-versus-host disease.
Which should the nurse monitor the child for after administering the drug?
1. Hyperglycemia
2. Hepatic toxicity
3. Seizures
4. Renal toxicity

Answer 8

1. Hyperglycemia
   Explanation:
2. Hyperglycemia is a side effect of steroid therapy.
3. Hepatic toxicity is not a side effect associated with steroid therapy.
4. Seizures are not a side effect associated with steroid therapy.
5. Renal toxicity is not a side effect associated with steroid therapy.

Question 9

After a severe allergic reaction, an EpiPen is prescribed for the school-age child. Which
instructions should the nurse provide to this child’s parents based on the current data? Select
all that apply.
1. “It is important that your child always has access to this medication.”
2. “Your child is too young to self-administer this medication.”
3. “If you are able to administer the medication, there is no need for follow-up care.”
4. “It is important to check the expiration date on the medication and replace if expired.”
5. “Your child should wear a Medic Alert bracelet at all times.”

Answer 9

1. “It is important that your child always has access to this medicine.”
2. “It is important to check the expiration date on the medication and replace if expired.”
3. “Your child should wear a medic alert bracelet at all times.”

Question 10

An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which
should the nurse include in the teaching session regarding an activity that should be
avoided?
1. Receiving a manicure and a pedicure
2. Washing the hair with shampoo daily
3. Using a tanning bed
4. Attending late night parties and dances

Answer 10

3. Using a tanning bed
   Explanation:
4. Manicures and pedicures do not place the teenager at any risk.
5. Although one symptom of SLE can be alopecia, gentle shampooing is not a cause of this
   symptom.
6. Individuals with SLE have photosensitivity, and tanning beds can lead to exacerbations
   as well as skin damage from sun burns.
7. Although adequate rest is important for the teenager with SLE, the teenager can “catch
   up” on her sleep the next day.

Question 11

Which is the priority nursing action when providing care to a pediatric client who has
documented allergies to cow’s milk, peanuts, and latex?
1. Evaluating the hospital room for equipment containing latex
2. Ordering an EpiPen for the child
3. Notifying dietary of the milk and peanut allergy
4. Placing a sign on the door which identifies all allergies

Answer 11

1. Evaluating the hospital room for equipment containing latex.
   Explanation:
2. This is appropriate as latex allergies can be life threatening. Many pieces of medical
   equipment may contain latex.
3. Nurses do not prescribe or dispense medication, so this is inappropriate.
4. This action should be taken but is not the priority.
5. Depending on hospital policy, there may be some sign to indicate allergies, but this is
   not the priority.

Question 12

Which is the rationale for ensuring the irrigation of blood products and ensuring that they
are cytomegalovirus (CMV)–negative prior to administering a blood transfusion for a
pediatric client diagnosed with severe combined immune deficiency (SCID)?
1. Transfusion reaction from lymphocytes and platelets in the donor blood.
2. Transfusion reaction and infection from lymphocytes in the donor blood.
3. Infection and graft-versus-host disease from lymphocytes in the donor blood.
4. Infection and graft-versus-host disease from erythrocytes in the donor blood.

Answer 12

3. Infection and graft-versus-host disease from lymphocytes in the donor blood.

Question 13

A nurse is planning care for a child with human immunodeficiency virus (HIV). Which is
the priority nursing diagnosis for this child?
1. Ineffective Peripheral Tissue Perfusion
2. Ineffective Thermoregulation
3. Risk for Fluid Volume Deficit
4. Risk for Infection

Answer 13

4. Risk for infection

Question 14

A child is receiving a nucleoside reverse transcriptase inhibitor for human
immunodeficiency virus (HIV). Which laboratory value should the nurse include in the plan
of care as needing to monitor?
1. Glucose
2. Sodium
3. Potassium
4. Red blood cell count

Answer 14

4. RBC count
   Explanation:
5. The glucose value is a laboratory test for checking diabetes. A nucleoside transcriptase
   inhibitor does not affect glucose values.
6. Sodium is an electrolyte. A nucleoside transcriptase inhibitor does not affect sodium
   values.
7. Potassium is an electrolyte. A nucleoside transcriptase inhibitor does not affect
   potassium values.
8. A nucleoside transcriptase inhibitor causes bone marrow suppression with resulting
   anemia. Red blood cell counts are monitored at least monthly for changes.

Question 15

A child with human immunodeficiency virus (HIV) is diagnosed with oral candidiasis.
Which should the nurse include in the plan of care related to oral care based on this
information?
1. Listerine
2. Normal saline
3. Viscous lidocaine
4. Scope

Answer 15

2. NS
   Explanation:
3. Listerine is a commercial mouth rinse that can have an alcohol base and cause drying of
   the membranes.
4. The mouth care should be with a nonalcohol base. Normal saline can keep the child’s
   lips and mouth moist.
5. Viscous lidocaine causes numbing, and could depress the gag reflex in a younger child.
6. Scope is a commercial mouth rinse that can have an alcohol base and cause drying of
   the membranes.

Question 16

The nurse is providing care for the family of a child who is diagnosed with acquired
immunodeficiency syndrome (AIDS). Which priority nursing diagnosis should the nurse
include in the plan of care?
1. Anticipatory Grieving
2. Risk for Impaired Parenting
3. Compromised Family Coping
4. Parental Role Conflict

Answer 16

1. Anticipatory grieving
   Explanation:
2. AIDS is not curable, so the problem nurses can anticipate, for all families, is
   Anticipatory Grieving.

Question 17

The nurse is providing discharge instructions to the family of a child who experienced an
anaphylactic reaction. Which parental statements indicate accurate understanding of the
action that histamine plays during this type of reaction? Select all that apply.
1. “Histamine releases IgE antibodies, which help to stop the reaction.”
2. “Histamine causes smooth muscle contraction, which causes the wheezing.”
3. “Histamine causes increased capillary permeability, which is what causes difficulty
breathing.”
4. “Histamine causes vasoconstriction leading to respiratory issues.”
5. “Histamine causes the destruction of red blood cells, which is why we administer the
EpiPen.”

Answer 17

2. “Histamine causes smooth muscle contraction, which causes wheezing.”
3. Histamine causes increased capillary permeability, which is what causes difficulty breathing.
   Explanation:
4. IgE antibodies cause the release of histamine, not the other way around.
5. Smooth muscle contraction causes the constriction of the bronchioles, which causes the
   wheezing and respiratory distress.
6. Increased capillary permeability causes the plasma to leak into surrounding tissues,
   including the lungs, leading to pulmonary edema.
7. Anaphylaxis causes vasodilation, not vasoconstriction.
8. Histamine does not cause red cell destruction.

Question 18

When teaching a pregnant client about antibodies that are passed from mother to newborn,
which antibody should the nurse include?
1. IgM
2. IgA
3. IgD
4. IgG

Answer 18

4. IgG
   Explanation:
5. IgM is the first antibody produced with primary immune response. It does not cross the
   placenta.
6. IgA does not cross the placenta.
7. Although the function of IgD is not fully understood, it is not thought to cross the
   placenta.
8. IgG crosses the placenta and provides the newborn with passive immunity.

Question 19

19) Which infection control measures should the nurse include in the discharge instructions for
the family of a child who is immunodeficient? Select all that apply.
1. “It is important that your child does not share cups with other members of the family.”
2. “You should avoid washing your child’s utensils in the dishwasher.”
3. “You should allow your child to eat fresh fruit with the skin intact.”
4. “It is important that everyone practices hand hygiene before touching your child.”
5. “You should use alcohol wipes to cleanse your child’s diaper area.”

Answer 19

1. “It is important that your child does not share cups with other members of the family.”
2. “It is important that everyone practices hand hygiene before touching your child.”
   Explanation:
3. Children who are immunodeficient should not share cups with other members of the
   family, as this increases the child’s risk for developing an infection.
4. Utensils should be washed in warm water or placed in the dishwasher to ensure that
   contaminates are properly cleansed.
5. Fresh fruit should be washed and peeled prior to allowing the child who is
   immunocomprised to eat it.
6. Hand hygiene before handling the child, after changing diapers, and prior to feeding the
   child is essential to decrease the risk for infection.
7. The diaper area should be cleaned with mild soap and allowed to dry. The use of alcohol
   will increase the risk for skin breakdown and infection.

Question 20

Which interventions should the nurse include in the plan of care to address nutrition for a
child who is diagnosed with acquired immunodeficiency syndrome (AIDS)? Select all that
apply.
1. Encourage three large meals each day.
2. Eliminate unpleasant odors from the environment during meals.
3. Weigh the child each day, using the same scale.
4. Assess skin turgor every 4 hours.
5. Include favorite foods in the meal plan.

Answer 20

2. Eliminate unpleasant odors from the environment during meals
3. Weigh the child each day, using the same scale.
4. Include favorite foods in the meal plan.
   Explanation:
5. Children diagnosed with AIDS who are experiencing impaired nutrition should be
   offered small frequent meals to meet nutritional needs.
6. Unpleasant stimuli and odors often decrease the desire for food.
7. Taking daily weights, using the same scale, is an appropriate intervention to monitor the
   child’s nutritional status.
8. Skin turgor should be assessed each shift, not every 4 hours, in order to monitor
   hydration status.
9. Allowing children to eat their favorite foods encourages intake.

Question 21

21) Which interventions should the nurse include in the plan of care for a hospitalized child who
is diagnosed with rheumatoid arthritis (RA)? Select all that apply.
1. Performing passive range-of-motion (ROM) exercises with the child
2. Discouraging the child from completing activities of daily living (ADLs)
3. Encouraging periods of rest for the child
4. Placing cool compresses on the child’s joints
5. Performing daily weights

Answer 21

1. Performing passive ROM exercises with the child
2. Encouraging periods of rest for the child.
3. Performing daily weights.

Question 22

The nurse is providing education to a family whose child experiences anaphylaxis when
exposed to any amount of latex. Which items, often found in the home or school
environment, should the nurse include in the teaching session? Select all that apply.
1. Art supplies
2. Toothpaste
3. Balloons
4. Perfumes
5. Chewing gum

Answer 22

1. Art supplies
2. Balloons
3. Chewing gum