Nokea
The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include?
- A. Edema
- B. Pulacheness
- C. Pallor
- D. Redness
- E. Warmth
Correct Answer: A,D,E
Rationale: The five cardinal signs of inflammation are redness (rubor), warmth (calor), pain (dolor), swelling (edema), and decreased function (functio laesa).
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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.
Which processes need to be functional and interact with each other for a person to be immunocompetent?
- A. Antibody-mediated immunity
- B. Cell-mediated immunity
- C. Inflammation
- D. Red blood cells
- E. White blood cells
Correct Answer: A,B,C
Rationale: Immunocompetence requires the interaction of antibody-mediated immunity, cell-mediated immunity, and inflammation to effectively protect the body against pathogens.
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.
A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
- A. Noticeable rubor
- B. Puniform learning
- C. Swelling and pain
- D. Warmth in the site
Correct Answer: B
Rationale: During the second phase of the inflammatory response, neutrophilia occurs, producing pus, which is assessed as purulent drainage or 'puniform learning' in the context of the question.
Which are steps in the process of making an antigen-specific antibody?
- A. Antibody-antigen binding
- B. Invasion
- C. Opsonization
- D. Recognition
- E. Sensitization
Correct Answer: A,B,D,E
Rationale: The process of making antigen-specific antibodies includes exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is a separate process where antibodies mark antigens for destruction.