Nokea
A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process?
- A. The cellular immune response
- B. Apoptosis
- C. Phagocytosis
- D. Opsonization
Correct Answer: B
Rationale: Apoptosis, or programmed cell death, is the bodys way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Opsonization is the coating of antigenantibody molecules with a sticky substance to facilitate phagocytosis. The body does not use phagocytosis or the cellular immune response to remove cells from circulation.
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A nurse is planning a patients care and is relating it to normal immune response. During what stage of the immune response should the nurse know that antibodies or cytotoxic T cells combine and destroy the invading microbes?
- A. Recognition stage
- B. Proliferation stage
- C. Response stage
- D. Effector stage
Correct Answer: D
Rationale: In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader. The coupling initiates a series of events that in most instances results in total destruction of the invading microbes or the complete neutralization of the toxin. This does not take place during the three preceding stages.
The nurse should recognize a patients risk for impaired immune function if the patient has undergone surgical removal of which of the following?
- A. Thyroid gland
- B. Spleen
- C. Kidney
- D. Pancreas
Correct Answer: B
Rationale: A history of surgical removal of the spleen, lymph nodes, or thymus may place the patient at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system.
An infection control nurse is presenting an inservice reviewing the immune response. The nurse describes the clumping effect that occurs when an antibody acts like a cross-link between two antigens. What process is the nurse explaining?
- A. Agglutination
- B. Cellular immune response
- C. Humoral response
- D. Phagocytic immune response
Correct Answer: A
Rationale: Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link between two antigens. This takes place within the context of the humoral immune response, but is not synonymous with it. Cellular immune response, the immune systems third line of defense, involves the attack of pathogens by T-cells. The phagocytic immune response, or immune response, is the systems first line of defense, involving white blood cells that have the ability to ingest foreign particles.
The nurse is assessing a clients risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity?
- A. The patient takes a beta blocker for the treatment of hypertension.
- B. The patient is under significant psychosocial stress.
- C. The patient had a pulmonary embolism 18 months ago.
- D. The patient has a family history of breast cancer.
Correct Answer: B
Rationale: Stress is a psychoneuroimmunologic factor that is known to depress the immune response. Use of beta blockers, a family history of cancer, and a prior PE are significant assessment findings, but none represents an immediate threat to immune function.
A nurse is caring for a patient who has had a severe antigen/antibody reaction. The nurse knows that the portion of the antigen that is involved in binding with the antibody is called what?
- A. Antibody lock
- B. Antigenic sequence
- C. Antigenic determinant
- D. Antibody channel
Correct Answer: C
Rationale: The portion of the antigen involved in binding with the antibody is referred to as the antigenic determinant. This portion is not known as an antibody lock, antigenic sequence, or antibody channel.