Nokea
A patient requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this patient most likely has what type of immune disorder?
- A. A primary immune deficiency
- B. A gammopathy
- C. An autoimmune disorder
- D. A rheumatic disorder
Correct Answer: A
Rationale: Primary immune deficiency results from improper development of immune cells or tissues. These disorders are usually congenital or inherited. Autoimmune disorders are less likely to have a genetic component, though some have a genetic component. Overproduction of immunoglobulins is the hallmark of gammopathies. Rheumatic disorders do not normally involve impaired immune function.
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A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact that her bone marrow is unable to produce a sufficient amount of what?
- A. Lymphocytes
- B. Cytoblasts
- C. Antibodies
- D. Capillaries
Correct Answer: A
Rationale: The white blood cells involved in immunity (including lymphocytes) are produced in the bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels.
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.
A patient with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the patient for which of the following complications of therapy?
- A. Immunosuppression
- B. Agranulocytosis
- C. Anemia
- D. Thrombocytopenia
Correct Answer: A
Rationale: Corticosteroids such as prednisone can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts.
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.
A patient is undergoing testing to determine the overall function of her immune system. What test can be performed to evaluate the functioning of the patients cellular immune system?
- A. Immunoglobulin testing
- B. Delayed hypersensitivity skin test
- C. Specific antibody response
- D. Total serum globulin assessment
Correct Answer: B
Rationale: Cellular (cell-mediated) immunity tests include the delayed hypersensitivity skin test, since this immune response is specifically dependent on the cellular immune response. Each of the other listed tests assesses functioning of the humoral immune system.