Immune Session 2 Flashcards
A HIV positive patient is admitted to the hospital for a severe infection. Their CD4 count is 180. Based on this criteria which statement made by the nurse is correct?
a. “The patient meets the criteria for a diagnosis of an acute HIV infection.”
b. “The patient will be diagnosed as in the latent stages of HIV infection.”
c. “The patient has developed acquired immunodeficiency syndrome (AIDS).”
d. “The patient will develop symptomatic chronic HIV infection in less than a year.”
C
Rationale: The diagnosis for AIDS is made when a HIV positive patient’s CD4 T cells drop below 200
A client who was tested for HIV after a recent exposure had a negative result. During the post-test counseling session, the nurse tells the client which of the following?
a) the test will need to be repeated
b) this ensures that the client is not infected with the HIV virus
c) the client no longer needs to protect himself from sexual partners
d) the client probably has immunity to the acquired immunodeficiency virus
A
Rationale: Western Blot Sequence testing is done in order to avoid the “window period” where a false negative can show
You have a patient who was recently diagnosed as AIDS positive. What is your priority nursing consideration with this patient?
A. Pain Management
B. Therapeutic communication
C. Place patient on fall risk precautions and ensure bedrails are up x 4
D. Infection control
D
Rationale: A patient who is AIDS positive is extremely immunocompromised and a minor infection could potentially be fatal
A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic sign of SLE?
A. Weight gain
B. Subnormal temperature
C. Elevated red blood cell count
D. Rash on the face across the bridge of the nose and on the cheeks
D
Rationale: A butterfly rash on the face is a classic sign of SLE
Define Antibody Vs Antigen
Antigen: a toxin or foreign body that induces an immune response
Antibody: a protein produced in RESPONSE to an antigen
The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care?
A. Protecting the client from infection
B. Providing emotional support to decrease fear
C. Encouraging discussion about lifestyle changes
D. Identifying factors that decreased the immune function
A
Rationale: This is the PRIORITY for a patient with an immunodeficiency disorder, 2,3, and 4 could be included but always remember SAFETY FIRST!
The nurse is assisting in administering immunizations at a health care clinic. The nurse educates the client on how vaccines work. Which statement made by the nurse is correct?
A. Protection from all diseases
B. Natural Passive Immunity from a specific disease
C. Natural Active Immunity from a specific disease
D. Artificial Immunity from a specific disease
D
Rationale: Natural immunity can only be attained from natural exposure to an antigen. An immunization is an artificial antigen and a controlled exposure resulting in antibody formation.
A mother asks the importance of breastmilk in her child’s developing immune system. The nurse would be correct in making which of the following statements?
A. Breastmilk only provides nutrition and does not affect immunity
B. Breastmilk provides natural active exposure to an antigen
C. Breastmilk provides an infant with natural passive exposure to antibodies
D. Breastmilk provides artificial exposure to an antigen
C
Rationale: A mother’s breastmilk provides Natural Passive exposure to mom’s antibodies
The nurse is explaining the importance of the body’s normal flora. Which of the following statements would be correct?
A. It is mechanical cleansing of the body surfaces through normal cell turnover
B. It is the closed barrier that protects the body from the outside environment
C. It is bacteria that lives on the body’s surfaces and provides protection against foreign bacteria
D. It triggers the degranulation of mast cells to release histamine
C
Rationale: the normal flora or microbiome is the natural bacteria that lives on the skin and GI tract. It has many functions - but one is to assist the immune system in combating harmful bacteria
The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is:
- A local rash that occurs as a result of allergy
- A disease caused by overexposure to sunlight
- An inflammatory disease caused by circulating immune complexes in the blood stream
- A disease caused by the continuous release of histamine in the body
3
Rationale: SLE is a type 3 hypersensitivity disorder which is characterized by circulating immune complexes in the blood stream
*remember type 3 = IgM or IgG mediated
A nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which of the following is the priority concern for this client?
A. Inability to care for self at home
B. Development of an infection
C. Lack of available support services
D. Isolation
B
Rationale: while all of these may be problems the PRIORITY is always safety. AIDS = immunocompromised and pregnancy can further compromise the immune system. This patient is at a heightened risk for fatal infections
Which Hypersensitivity disorder targets specific cells for destruction?
A. Type 1
B. Type 2
C. Type 3
D. Type 4
B
Rationale: type 2 hypersensitivity disorders are cell specific
*Remember these are IgG or IgM mediated
A client is noted to have a type I hypersensitivity reaction with a systemic response. Which clinical manifestation should the nurse anticipate? SATA
A. Hypertension B. Pallor C. Wheezing D. Urticaria (itching) E. Hypotension
C,D,E
Rationale: These are expected CM of a systemic type 1 hypersensitivity reaction.
Which is the nurse’s PRIORITY action when managing a client experiencing a type I hypersensitivity?
A. Pain management
B. Airway management
C. Administering medications to lower BP
D. Decreasing a fever
B
Rationale: AIRWAY (ABCs and safety first!)
What are the functions of the inflammatory response: SATA
A. Decrease pain B. Limit amount of damage to tissues C. Provide specific protection against an invading antigen D. Dilute and Destroy foreign antigens E. Begin the healing process
B,D,E
Rationale: the IR does not decrease pain and it provides NON SPECIFIC protection so A and C are incorrect
