Nokea
The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?
- A. CD4+ cells
- B. Covered T cells
- C. Natural killer cells
- D. Suppressor T cells
Correct Answer: D
Rationale: Suppressor T cells (also known as regulatory T cells) help prevent hypersensitivity to one's own cells. Dysfunction in these cells can lead to autoimmune diseases.
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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 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.
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.
A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
- A. Noticeable rubor
- B. Puniform learning
- C. Swelling and pain
- D. Warmth in the site
Correct Answer: B
Rationale: During the second phase of the inflammatory response, neutrophilia occurs, producing pus, which is assessed as purulent drainage or 'puniform learning' in the context of the question.
A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissues or organ?
- A. Bone marrow
- B. Spleen
- C. Thymus
- D. Cells
Correct Answer: A
Rationale: The B cell, which is the primary cell in antibody-mediated immunity, originates and is released from the bone marrow before traveling to secondary lymphoid tissues.