Unit D-Immune Response: Complex Connective Tissue Disease Problems

Question 1

The nurse learns that the most important function of inflammation and immunity is which
purpose?
a. Destroying bacteria before damage occurs
b. Preventing any entry of foreign material
c. Providing maximum protection against infection
d. Regulating the process of self-tolerance

Answer 1

ANS: C
Immunity and Inflammation working together are critical to maintaining health, preventing
disease, and repairing tissue damage. When all the different parts and functions of immunity
are working well, the adult is immunocompetent and has maximum protection against
infection. Working together, their function is not limited to destroying bacteria before damage
occurs. They do not prevent the entry of all foreign materials and immunity alone regulates
the process of self-tolerance.

Question 2

A nurse is assessing an older client for the presence of infection. The client’s temperature is

97. 6° F (36.4° C). What response by the nurse is best?
    a. Assess the client for more specific signs.
    b. Conclude that an infection is not present.
    c. Document findings and continue to monitor.
    d. Request the primary health care provider order blood cultures.

Answer 2

ANS: A
Because older adults have decreased immune function, including reduced neutrophil function,
fever may not be present during an episode of infection. The nurse would assess the client for
specific signs of infection. Documentation needs to occur, but a more thorough assessment
comes first. Blood cultures may or may not be needed depending on the results of further
assessment.

Question 3

A clinic nurse is working with an older client. What action is most important for preventing
infections in this client?
a. Assessing vaccination records for booster shot needs
b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes

Answer 3

ANS:A
Older adults may have insufficient antibodies that have already been produced against
microbes to which they have been exposed. Therefore, older adults need booster shots for
many vaccinations they received as younger people. A nutritious diet, proper wound care, and
hand hygiene are relevant for all populations.

Question 4

A client has a leg wound that is in Stage II of the inflammatory response. For what sign or
symptom does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site

Answer 4

ANS: B
During the second phase of the inflammatory response, neutrophilia occurs, producing pus.
Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory
process.

Question 5

A nurse learning about antibody-mediated immunity learns that the cell with the most direct
role in this process begins development in which tissue or organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils

Answer 5

ANS: A
The B-cell is the primary cell in antibody-mediated immunity and is released from the bone
marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid
tissues for B-cells.

Question 6

The nurse understands that which type of immunity is the longest acting?

a. Artificial active
b. Inflammatory
c. Natural active
d. Natural passive

Answer 6

ANS: C
Natural active immunity is the most effective and longest acting type of immunity. Artificial
and natural passive do not last as long. “Inflammatory” is not a type of immunity.

Question 7

The nurse working with clients who have autoimmune diseases understands that what
component of cell-mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T-cells
c. Natural killer cells
d. Regulator T-cells

Answer 7

ANS: D
Regulator T-cells help prevent hypersensitivity to one’s own cells, which is the basis for
autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete
cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first
being sensitized. Regulator T-cells have an inhibitory action on the immune system. Cytotoxic
T-cells are effective against self cells infected by parasites such as viruses or protozoa.

Question 8

A primary health care provider notifies the nurse that a client has a “bandemia.” What action
does the nurse anticipate?
a. Administer antibiotics.
b. Place the client in isolation.
c. Administer IV leukocytes.
d. Obtain an immunization history.

Answer 8

ANS: A
A bandemia, or shift to the left, in the white count differential means that an acute, continuing
infection has placed so much stress on the immune system that the most numerous type of
neutrophil in circulation are immature, or band cells. The nurse would anticipate
administering antibiotics. The client may or may not need isolation. Leukocyte infusion and
immunization history are not relevant.

Question 9

What does the nurse learn about the function of colony-stimulating factor?

a. Triggers the bone marrow to shorten the time needed to produce mature WBCs.
b. Causes capillary leak in acute inflammation.
c. Responsible for creating exudate (pus) at infectious sites.
d. Dilates blood vessels at the site of inflammation leading to hyperemia.

Answer 9

ANS: A
Colony-stimulating factor triggers the bone marrow to shorten the time needed to produce
mature WBCs from about 14 days to hours. Increased blood flow to the local area of
inflammation produces hyperemia, or redness. Exudate is formed by neutrophils and consists
of dead WBCs, necrotic tissue, and fluids that escape from damaged cells. Histamine,
serotonin, and kinins dilate arterioles leading to redness and warmth.

Question 10

The older client’s adult child questions the nurse as to why the client is at higher risk for
infection when the client’s white cell count is within the normal range. What response by the
nurse is best?
a. “The white cell count does not tell us everything about immunity.”
b. “White blood cells are less active in older people so they are not as efficient.”
c. “Older people typically have poor nutrition which makes them prone to infection.”
d. “As one ages, immunoglobulins cease to be produced in response to illness.”

Answer 10

ANS: B
An age-related change in immunity is that neutrophils in the older adult are less active and
therefore less effective in immunity. The white blood cell count is not the only thing that can
inform about immunity, but this response is too vague to be useful. Many older adults do have
poor nutrition that does affect immunity, but this is not true for everyone and the stem does
not contain information stating that is problematic for this older adult. Immunoglobulins do
not cease to be produced with age.

Question 11

For a person to be immunocompetent, which processes need to be functional and interact
appropriately with each other? (Select all that apply.)
a. Antibody-mediated immunity
b. Cell-mediated immunity
c. Inflammation
d. Red blood cells
e. White blood cells

Answer 11

ANS: A, B, C
The three processes that need to be functional and interact with each other for a person to be
immunocompetent are antibody-mediated immunity, cell-mediated immunity, and
inflammation. Red and white blood cells are not processes.

Question 12

A nurse is learning about the types of different cells involved in the inflammatory response.
Which principles does the nurse learn? (Select all that apply.)
a. Basophils are only involved in the general inflammatory process.
b. Eosinophils increase during allergic reactions and parasitic invasion.
c. Macrophages can participate in many episodes of phagocytosis.
d. Monocytes turn into macrophages after they enter body tissues.
e. Neutrophils can only take part in one episode of phagocytosis.

Answer 12

ANS: B, C, D, E
Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in
many episodes of phagocytosis. Monocytes turn into macrophages after they enter body
tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in
both the general inflammatory response and allergic or hypersensitivity responses.

Question 13

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does
this include? (Select all that apply.)
a. Edema
b. Pulselessness
c. Pallor
d. Redness
e. Warmth
f. Decreased function

Answer 13

ANS: A, D, E, F
The five cardinal signs of inflammation include redness, warmth, pain, swelling, and
decreased function.

Question 14

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.)

a. Antibody-antigen binding
b. Invasion
c. Opsonization
d. Recognition
e. Sensitization
f. Production

Answer 14

ANS: A, B, D, E, F
The seven steps in the process of making antigen-specific antibodies are: exposure/invasion,
antigen recognition, sensitization, antibody production and release, antigen-antibody binding,
antibody binding actions, and sustained immunity. Opsonization is the adherence of an
antibody to the antigen, marking it for destruction.

Question 15

The nurse is learning about immunoglobulins. . Which principles does the nurse learn? (Select
all that apply.)
a. IgA is found in high concentrations in secretions from mucous membranes.
b. IgD is present in the highest concentrations in mucous membranes.
c. IgE is associated with antibody-mediated hypersensitivity reactions.
d. IgG comprises the majority of the circulating antibody population.
e. IgM is the first antibody formed by a newly sensitized B-cell.

Answer 15

ANS: A, C, D, E
Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous
membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity
reactions. The majority of the circulating antibody population consists of immunoglobulin G
(IgG). The first antibody formed by a newly sensitized B-cell is immunoglobulin M (IgM).
Immunoglobulin D (IgD) is typically present in low concentrations.

Question 16

The nurse learns that which risk factors can affect immunity? (Select all that apply.)

a. Age
b. Environmental factors
c. Ethnicity
d. Drugs
e. Nutritional status

Answer 16

ANS: A, B, D, E
Immunity changes during an adult’s life as a result of nutritional status, environmental
conditions, drugs, disease, and age. Immunity is most efficient in young adults and older
adults have decreased immune function. Ethnicity does not affect immunity.

Question 17

The nurse is teaching an elderly client the risks of infection for older adults. Which of the
following factors would the nurse include in the education? (Select all that apply.)
a. Higher risk for respiratory tract and genitourinary infections.
b. May not have a fever with severe infection.
c. Show expected changes in white blood cell counts.
d. Should receive influenza, pneumococcal, and shingles vaccinations.
e. Skin tests for tuberculosis may be falsely negative.
f. Booster vaccinations are not likely needed as one ages.

Answer 17

ANS: A, B, D, E
Immunity changes during an adult’s life and older adults have decreased immune function.
The number and function of neutrophils and macrophages are reduced leading to reduced
response to infection and injury, such as temperature elevation. The usual response of an
increased white blood cell count is delayed or absent. Older adults are less able to make new
antibodies in response to the presence of new antigens requiring repeat vaccinations and
immunizations. Skin tests for tuberculosis may be falsely negative and there is an increased
risk for bacterial and fungal infections due to the decreased number of circulating
T-lymphocytes.

Question 18

A nurse is studying the functions of specific leukocytes. Which leukocytes are matched
correctly with their function? (Select all that apply.)
a. Monocyte: matures into a macrophage.
b. Basophil: releases vasoactive amines during an allergic reaction.
c. Plasma cell: secretes immunoglobulins in response to the presence of a specific
antigen.
d. Cytotoxic T-cells: attacks and destroys ingested poisons and toxins.
e. Natural killer cell: nonselectively attacks non-self cells.
f. Regulator T-cells: become sensitized for self-recognition in the bone marrow.

Answer 18

ANS: A, C, E
Monocytes mature into macrophages, plasma cells secrete immunoglobulin in the presence of
specific antigens, and natural killer cells nonselectively attack non-self cells. Basophils release
histamines, kinins, and heparin in areas of tissue damage. Cytotoxic T-cells selectively attack
and destroy non-self cells, including virally infected cells, grafts, and transplanted organs.
Regulator T-cells become sensitized for self-recognition in the thymus.

Question 19

A nurse is studying the function of immunoglobulins. Which immunoglobulins are correctly
matched to their function? (Select all that apply.)
a. IgA: most responsible for preventing infection in the respiratory tracts, the GI
tract, and the genitourinary tract.
b. IgD: provides protection against parasite infestations, especially helminths.
c. IgE: associated with antibody-mediated immediate hypersensitivity reactions.
d. IgG: activates classic complement pathway and enhances neutrophil and
macrophage actions.
e. IgM: first antibody formed by a newly sensitized B-lymphocyte plasma cell.

Answer 19

ANS: A, C, D, E
All options are true except IgD acts as a B-cell antigen receptor. IgE provides protection
against parasite infestations, especially helminths.

Question 20

The nurse caring for clients assesses their daily laboratory profiles. Which lab results are
considered to be in the normal range? (Select all that apply.)
a. Segmented neutrophils: 68%
b. Bands: 19%
c. Monocytes: 12%
d. Lymphocytes: 38%
e. Eosinophils: 2%
f. Basophils: 1%

Answer 20

ANS: A, D, E, F
The normal range for segmented neutrophils is 55% to 70%. The normal range for bands is
5%. The normal range for monocytes is 2% to 8%. The normal range for lymphocytes is 20%
to 40%. The normal range for eosinophils is 1% to 4%. The normal range for basophils is
0.5% to 1%.

Question 21

What statements about the complement system are correct? (Select all that apply.)

a. Comprised of 20 types of inactive plasma proteins.
b. Act as enzymes when activated to enhance innate immunity.
c. Phagocytize foreign invaders quickly by destroying their membranes.
d. Sticks to the antigen and forms a membrane attack complex.
e. Maintain and prolong inflammation from non-self cells.
f. Is part of the innate immune system.

Answer 21

ANS: A, B, D, F
The complement system is made up of 20 different types of inactive plasma proteins that,
when activated, act as enzymes to enhance (or complement) cell actions in innate immunity.
They join other proteins to surround antigens and “fix” or stick to the antigen quickly forming
a membrane attack complex on the antigen surface. This action makes immune cell
attachment to antigens and phagocytosis more efficient. They are part of innate immunity.
They do not phagocytize invaders themselves nor do they maintain and prolong inflammation
from allergens.

Question 22

A nurse is teaching the client with systemic lupus erythematosus about prednisone. What
information is the priority?
a. Might make the client feel jittery or nervous.
b. Can cause sodium and fluid retention.
c. Long-term effects include fat redistribution.
d. Never stop prednisone abruptly.

Answer 22

ANS: D
The nurse teaches the client to avoid stopping the drug abruptly as the priority because this
can lead to a life-threatening adrenal crisis. Short-term side effects do include jitteriness or
nervousness, sodium and water retention. One long-term side effect is fat redistribution
resulting in “moon face” and “buffalo hump.”

Question 23

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help
prevent a client from having a type II hypersensitivity reaction?
a. Administering steroids for a positive TB test
b. Correctly identifying the client prior to a blood transfusion
c. Keeping the client free of the offending agent
d. Providing a latex-free environment for the client

Answer 23

ANS: B
A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These
can be prevented by correctly identifying the client and cross-checking the unit of blood to be
administered. A positive type IV response is a positive TB test. Avoidance therapy is the
cornerstone of treatment for a type IV hypersensitivity to substances that are known and can
be avoided such as poison ivy and insect stings. Latex allergies are a type I hypersensitivity.

Question 24

A client has been newly diagnosed with systemic lupus erythematosus and is reviewing
self-care measures with the nurse. Which statement by the client indicates a need to review the
material?
a. “I will avoid direct sunlight as much as possible.”
b. “Baby powder is good for the constant sweating.”
c. “Grouping errands will help prevent fatigue.”
d. “Rest time will have to become a priority.”

Answer 24

ANS:B
Constant sweating is not a sign of SLE and powders are drying so they should not be used, at
least not in excess. The client is correct in stating he/she should avoid direct sunlight, that
grouping errands can prevent or reduce fatigue, and that rest will have to become a priority.

Question 25

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped
with over-the-counter antihistamines. What response by the nurse is most appropriate?
a. “Antihistamines do not help poison ivy.”
b. “There are different antihistamines to try.”
c. “You should be seen in the clinic right away.”
d. “You will need to take some IV steroids.”

Answer 25

ANS: A
Since histamine is not the mediator of a type IV reaction such as with poison ivy,
antihistamines will not provide relief. The nurse would educate the client about this. The
client does not need to be seen right away. The client may or may not need steroids; they may
be given either IV or orally.

Question 26

A nurse has educated a client on an epinephrine autoinjector. What statement by the client
indicates additional instruction is needed?
a. “I don’t need to go to the hospital after using it.”
b. “I must carry two autoinjectors with me at all times.”
c. “I will write the expiration date on my calendar.”
d. “This can be injected right through my clothes.”

Answer 26

ANS: A
Clients would be instructed to call 911 and go to the hospital for monitoring after using the
autoinjector. The medication may wear off before the offending agent has cleared the client’s
system. The other statements show good understanding of this treatment.

Question 27

A nurse has presented an educational program to a community group on Lyme disease. What
statement by a participant indicates the need to review the material?
a. “I should take precautions against ticks, especially in the summer.”
b. “A red rash that looks like a bull’s-eye may be one of the symptoms.”
c. “If Lyme disease is not treated successfully, it is usually fatal.”
d. “For Stage I disease, antibiotics are usually needed for 14 to 21 days.”

Answer 27

ANS:C
Untreated Lyme disease can lead to chronic complications, or Stage III Lyme disease, such as
arthritis, chronic fatigue, memory/thinking problems. It is not usually a fatal disease so this
information would need to be corrected by the nurse. The other participant statements are
correct.

Question 28

The nurse is studying hypersensitivity reactions. Which reactions are correctly matched with
their hypersensitivity types? (Select all that apply.)
a. Type I—examples include hay fever and anaphylaxis.
b. Type II—mediated by action of immunoglobulin M (IgM).
c. Type III—immune complex deposits in blood vessel walls.
d. Type IV—examples are poison ivy and transplant rejection.
e. Type IV—involve both antibodies and complement.

Answer 28

ANS: A, C, D
Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis,
and allergic asthma. Type III reactions consist of immune complexes that form and deposit in
the walls of blood vessels. Type IV reactions include responses to poison ivy exposure,
positive tuberculosis tests, and graft rejection. Type II reactions are mediated by
immunoglobulin G, not IgM. Type IV hypersensitivity reactions do not involve either
antibodies or complement.

Question 29

The nurse is assessing a client for signs and symptoms of systemic lupus erythematosus
(SLE). Which of the following would be consistent with this disorder? (Select all that apply.)
a. Discoid rash on skin exposed to sunlight
b. Urinalysis positive for casts and protein
c. Painful, deformed small joints
d. Pain on inspiration
e. Thrombocytosis
f. Serum positive for antinuclear antibodies (ANA)

Answer 29

ANS: A, B, D, F
Signs and symptoms of SLE include (but are not limited to) a discoid rash on skin exposed to
the sun, urinalysis with casts and protein, pleurisy as manifested by pain on inspiration, and
positive ANA titers in the blood. Nonerosive arthritis in peripheral joints can occur but does
not lead to deformity. Thrombocytopenia is another sign.

Question 30

A client is being administered the first dose of belimumab for a systemic lupus erythematosus

flare. What actions by the nurse are most appropriate? (Select all that apply.)
a. Observe the client for at least 2 hours afterward.
b. Instruct the client about the monthly infusion schedule.
c. Inform the client not to drive or sign legal papers for 24 hours.
d. Ensure emergency equipment is working and nearby.
e. Make a follow-up appointment for a lipid panel in 2 months.
f. Instruct the client to hold other medications for 72 hours.

Answer 30

ANS:A,D
This drug is a monoclonal antibody to tumor necrosis factor. The first dose would be
administered in a place where severe allergic reactions and/or anaphylaxis can be managed.
This includes having emergency equipment nearby. The client would be observed for at least
2 hours after this first dose. This drug does not cause drowsiness, so there would be no
restrictions on driving or signing legal documents. Elevated lipids are not associated with this
drug. This drug is used in combination with other therapies, especially during a flare.

Question 31

A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding
the most common causes of death for these clients is which of the following? (Select all that
apply.)
a. Infection
b. Cardiovascular impairment
c. Vasculitis
d. Chronic kidney disease
e. Liver failure
f. Blood dyscrasias

Answer 31

ANS: B, D
Any and all organs and tissues may be affected in SLE but the most common causes of death
in clients with SLE include cardiovascular impairment and chronic kidney disease.