Nokea
The nurse should recognize a patients risk for impaired immune function if the patient has undergone surgical removal of which of the following?
- A. Thyroid gland
- B. Spleen
- C. Kidney
- D. Pancreas
Correct Answer: B
Rationale: A history of surgical removal of the spleen, lymph nodes, or thymus may place the patient at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system.
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A patient is being treated for cancer and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which of the following ways?
- A. Causing apoptosis of cytokines
- B. Increasing interferon production
- C. Causing CD4+ cells to mutate
- D. Depressing antibody response
Correct Answer: D
Rationale: Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. This specific nutritional deficit does not cause T-cell mutation, an increase in the production of interferons, or apoptosis of cytokines.
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.
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 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 requires ongoing treatment and infection-control precautions because of an inherited deficit in immune function. The nurse should recognize that this patient most likely has what type of immune disorder?
- A. A primary immune deficiency
- B. A gammopathy
- C. An autoimmune disorder
- D. A rheumatic disorder
Correct Answer: A
Rationale: Primary immune deficiency results from improper development of immune cells or tissues. These disorders are usually congenital or inherited. Autoimmune disorders are less likely to have a genetic component, though some have a genetic component. Overproduction of immunoglobulins is the hallmark of gammopathies. Rheumatic disorders do not normally involve impaired immune function.