The nurse understands that which type of immunity is the longest acting?
- A. Artificial active
- B. Inflammatory
- C. Natural active
- D. Natural passive
Correct Answer: C
Rationale: Natural active immunity, acquired through exposure to an antigen, is the most effective and longest-lasting type of immunity compared to artificial active, natural passive, or inflammatory responses.
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A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
- A. Assessing vaccination records for booster shot needs
- B. Encouraging the client to eat a nutritious diet
- C. Instructing the client to wash minor wounds carefully
- D. Teaching hand hygiene to prevent the spread of microbes
Correct Answer: A
Rationale: Older adults may have insufficient antibodies against microbes to which they have been exposed. Assessing vaccination records ensures they receive necessary booster shots to maintain immunity.
A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
- A. Kidney transplant
- B. High-dose steroid administration
- C. Monoclonal antibody therapy
- D. Plasmapheresis
Correct Answer: A
Rationale: Hyperacute rejection occurs within minutes of transplantation and is irreversible. The organ must be removed, and the client returns to dialysis.
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.
A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn?
- A. Basophils are only involved in the general inflammatory process
- B. Basophils are only involved in the general inflammatory process
- C. Macrophages participate in many episodes of phagocytosis
- D. Monocytes turn into macrophages after they enter body tissues
- E. Neutrophils can only take part in one episode of phagocytosis
Correct Answer: B,C,D,E
Rationale: Basophils are involved in both general inflammation and allergic/hypersensitivity responses. Macrophages can perform multiple phagocytosis episodes, monocytes differentiate into macrophages in tissues, and neutrophils are limited to one phagocytosis event.
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.
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