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The nurse is assessing a clients risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity?
- A. The patient takes a beta blocker for the treatment of hypertension.
- B. The patient is under significant psychosocial stress.
- C. The patient had a pulmonary embolism 18 months ago.
- D. The patient has a family history of breast cancer.
Correct Answer: B
Rationale: Stress is a psychoneuroimmunologic factor that is known to depress the immune response. Use of beta blockers, a family history of cancer, and a prior PE are significant assessment findings, but none represents an immediate threat to immune function.
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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 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.
A patient is vigilant in her efforts to take good care of herself but is frustrated by her recent history of upper respiratory infections and influenza. What aspect of the patients lifestyle may have a negative effect on immune response?
- A. The patient works out at the gym twice daily.
- B. The patient does not eat red meats.
- C. The patient takes over-the-counter dietary supplements.
- D. The patient sleeps approximately 6 hours each night.
Correct Answer: A
Rationale: Rigorous exercise or competitive exercise usually considered a positive lifestyle factor can be a physiologic stressor and cause negative effects on immune response. The patients habits around diet and sleep do not present obvious threats to immune function.
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.