Nokea
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.
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A nursing student is giving a report on the immune system. What function of cytokines should the student describe?
- A. Determining whether a cell is foreign
- B. Determining if lymphokines will be activated
- C. Determining whether the T cells will remain in the nodes and retain a memory of the antigen
- D. Determining whether the immune response will be the production of antibodies or a cell-mediated response
Correct Answer: D
Rationale: Separate subpopulations of helper T cells produce different types of cytokines and determine whether the immune response will be the production of antibodies or a cell-mediated immune response. Cytokines do not determine whether cells are foreign, determine if lymphokines will be activated, or determine the role of memory T cells.
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.
A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of her last tetanus shot, which is over 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what?
- A. Antibodies
- B. Antigens
- C. Cytokines
- D. Phagocytes
Correct Answer: A
Rationale: Immunizations activate the humoral immune response, culminating in antibody production. Antigens are the substances that induce the production of antibodies. Immunizations do not prompt cytokine or phagocyte production.
A nurse has admitted a patient who has been diagnosed with urosepsis. What immune response predominates in sepsis?
- A. Mitigated
- B. Nonspecific
- C. Cellular
- D. Humoral
Correct Answer: D
Rationale: Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. For example, during transplantation rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant role. Neither mitigated nor nonspecific cell response is noted in this situation.
A patients exposure to which of the following microorganisms is most likely to trigger a cellular response?
- A. Herpes simplex
- B. Staphylococcus aureus
- C. Pseudomonas aeruginosa
- D. Beta hemolytic Streptococcus
Correct Answer: A
Rationale: Viral, rather than bacterial antigens, induce a cellular response.