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.
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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.
A nurse is planning a patients care and is relating it to normal immune response. During what stage of the immune response should the nurse know that antibodies or cytotoxic T cells combine and destroy the invading microbes?
- A. Recognition stage
- B. Proliferation stage
- C. Response stage
- D. Effector stage
Correct Answer: D
Rationale: In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader. The coupling initiates a series of events that in most instances results in total destruction of the invading microbes or the complete neutralization of the toxin. This does not take place during the three preceding stages.
A patient is undergoing testing to determine the overall function of her immune system. What test can be performed to evaluate the functioning of the patients cellular immune system?
- A. Immunoglobulin testing
- B. Delayed hypersensitivity skin test
- C. Specific antibody response
- D. Total serum globulin assessment
Correct Answer: B
Rationale: Cellular (cell-mediated) immunity tests include the delayed hypersensitivity skin test, since this immune response is specifically dependent on the cellular immune response. Each of the other listed tests assesses functioning of the humoral immune system.
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.
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.
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