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An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best?
- A. Administer pneumonia vaccination
- B. Recognize the client may have a false negative TB test
- C. Teach the client about viral infections
- D. Treat the client as if he or she has tuberculosis (TB)
- E. Tell the client to rest and drink plenty of fluids
Correct Answer: D
Rationale: Due to age-related decreases in T lymphocytes, older adults may have a falsely negative TB test. Given symptoms suggestive of TB, the nurse should treat the client as if they have TB.
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The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ?
- A. Child
- B. Identical twin
- C. Parent
- D. Same-sex sibling
Correct Answer: B
Rationale: An identical twin is the best donor because their genetic makeup is identical to the recipient, minimizing the risk of rejection.
The nurse understands that which type of immunity is the longest acting?
- A. Artificial active
- B. Inflammatory
- C. Natural active
- D. Natural passive
Correct Answer: C
Rationale: Natural active immunity, acquired through exposure to an antigen, is the most effective and longest-lasting type of immunity compared to artificial active, natural passive, or inflammatory responses.
A nurse is assessing any older client for the presence of infection. The clients 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. Conclude that an infection is not present.
- D. Request that the provider order blood cultures.
Correct Answer: A
Rationale: Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection.
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.