Nokea
A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
- A. Noticeable rubor
- B. Puniform learning
- C. Swelling and pain
- D. Warmth in the site
Correct Answer: B
Rationale: During the second phase of the inflammatory response, neutrophilia occurs, producing pus, which is assessed as purulent drainage or 'puniform learning' in the context of the question.
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A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissues or organ?
- A. Bone marrow
- B. Spleen
- C. Thymus
- D. Cells
Correct Answer: A
Rationale: The B cell, which is the primary cell in antibody-mediated immunity, originates and is released from the bone marrow before traveling to secondary lymphoid tissues.
A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best?
- A. Increases the elimination of T lymphocytes from circulation
- B. It inhibits cytokine production in most lymphocytes
- C. It inhibits cytokine production in most lymphocytes
- D. It prevents the activation of the lymphocytes responsible for rejection
Correct Answer: A
Rationale: Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that increases the elimination of T lymphocytes from circulation, reducing the immune response to prevent transplant rejection.
A clinic nurse is working with an older client. What assessment 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
Correct Answer: A
Rationale: Older adults may have insufficient antibodies against microbes to which they have been exposed. Assessing vaccination records ensures they receive necessary booster shots to maintain immunity.
The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?
- A. CD4+ cells
- B. Covered T cells
- C. Natural killer cells
- D. Suppressor T cells
Correct Answer: D
Rationale: Suppressor T cells (also known as regulatory T cells) help prevent hypersensitivity to one's own cells. Dysfunction in these cells can lead to autoimmune diseases.
The student nurse learns that the most important function of inflammation and immunity is which purpose?
- A. The majority has bacteria of damage vaccines.
- B. Preventing any entry of foreign material
- C. Providing protection against invading organisms
- D. Regulating the process of self-tolerance
Correct Answer: C
Rationale: The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents.