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A nurse is reviewing the immune system before planning an immunocompromised patients care. How should the nurse characterize the humoral immune response?
- A. Specialized cells recognize and ingest cells that are recognized as foreign.
- B. T lymphocytes are assisted by cytokines to fight infection.
- C. Lymphocytes are stimulated to become cells that attack microbes directly.
- D. Antibodies are made by B lymphocytes in response to a specific antigen.
Correct Answer: D
Rationale: The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. Phagocytosis and direct attack on microbes occur in the context of the cellular immune response.
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A patient was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response?
- A. Effector
- B. Proliferation
- C. Response
- D. Recognition
Correct Answer: B
Rationale: In the proliferation stage, T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. This does not occur in the response, recognition, or effector stages.
A nurse is planning the assessment of a patient who is exhibiting signs and symptoms of an autoimmune disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is known to be higher among what group?
- A. Young adults
- B. Native Americans
- C. Women
- D. Hispanics
Correct Answer: C
Rationale: Many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones.
A patients injury has initiated an immune response that involves inflammation. What are the first cells to arrive at a site of inflammation?
- A. Eosinophils
- B. Red blood cells
- C. Lymphocytes
- D. Neutrophils
Correct Answer: D
Rationale: Neutrophils are the first cells to arrive at the site where inflammation occurs. Eosinophils increase in number during allergic reactions and stress responses, but are not always present during inflammation. RBCs do not migrate during an immune response. Lymphocytes become active but do not migrate to the site of inflammation.
The nurse is completing a focused assessment addressing a patients immune function. What should the nurse prioritize in the physical assessment?
- A. Percussion of the patients abdomen
- B. Palpation of the patients liver
- C. Auscultation of the patients apical heart rate
- D. Palpation of the patients lymph nodes
Correct Answer: D
Rationale: During the assessment of immune function, the anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement. If palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Because of the central role of lymph nodes in the immune system, they are prioritized over the heart, liver, and abdomen, even though these would be assessed.
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.