Nokea
Diagnostic testing has revealed a deficiency in the function of a patients complement system. This patient is likely to have an impaired ability to do which of the following?
- A. Protecting the body against viral infection
- B. Marking the parameters of the immune response
- C. Bridging natural and acquired immunity
- D. Collecting immune complexes during inflammation
Correct Answer: C
Rationale: Complement has three major physiologic functions: defending the body against bacterial infection, bridging natural and acquired immunity, and disposing of immune complexes and the byproducts associated with inflammation. Complement does not mark the parameters of the immune response; complement does not collect immune complexes during inflammation.
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A gerontologic nurse is caring for an older adult patient who has a diagnosis of pneumonia. What age-related change increases older adults susceptibility to respiratory infections?
- A. Atrophy of the thymus
- B. Bronchial stenosis
- C. Impaired ciliary action
- D. Decreased diaphragmatic muscle tone
Correct Answer: C
Rationale: As a consequence of impaired ciliary action due to exposure to smoke and environmental toxins, older adults are vulnerable to lung infections. This vulnerability is not the result of thymus atrophy, stenosis of the bronchi, or loss of diaphragmatic muscle tone.
A patients current immune response involves the direct destruction of foreign microorganisms. This aspect of the immune response may be performed by what cells?
- A. Suppressor T cells
- B. Memory T cells
- C. Cytotoxic T cells
- D. Complement T cells
Correct Answer: C
Rationale: Cytotoxic T cells (also called CD8 + cells) participate in the destruction of foreign organisms. Memory T cells and suppressor T cells do not perform this role in the immune response. The complement system does not exist as a type of T cell.
The nurse knows that the response of natural immunity is enhanced by processes that are inherent in the physical and chemical barriers of the body. What is a chemical barrier that enhances the response of natural immunity?
- A. Cell cytoplasm
- B. Interstitial fluid
- C. Gastric secretions
- D. Cerebrospinal fluid
Correct Answer: C
Rationale: Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi. Not all body fluids are chemical barriers, however. Cell cytoplasm, interstitial fluid, and CSF are not normally categorized as chemical barriers to infection.
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.
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.