Nokea
Which situation is an example of immunocompetence?
- A. A child that is immune to measles because of an inoculation
- B. A person who has seasonal allergies every fall
- C. When the symptoms of a common cold disappear in 1 day
- D. A neonate having a natural immunity from maternal antibodies
Correct Answer: C
Rationale: Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimulus and the body's integrity is maintained as with cold symptoms that resolve without residual illness.
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A patient is admitted with a secondary immunodeficiency from chemotherapy. The nurse expects the plan of care to focus on which aspect?
- A. infection control.
- B. supporting self-care.
- C. nutritional education.
- D. maintaining high fluid intake.
Correct Answer: A
Rationale: Immune deficient persons are at risk for infection and need to be protected aggressively for contagion.
Immediately after the nurse administers an intradermal injection of a suspected antigen during allergy testing, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially?
- A. Elevate the arm above the shoulder.
- B. Administer subcutaneous epinephrine.
- C. Apply a warm compress to area.
- D. Apply a local antiinflammatory cream to the site.
Correct Answer: B
Rationale: Injection of subcutaneous epinephrine should be given at the first sign of allergy.
How does normal aging change the immune system?
- A. Depresses bone marrow.
- B. T cells become hyperactive.
- C. B cells show deficiencies in activity.
- D. Increase in the size of the thymus.
Correct Answer: C
Rationale: Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is essentially uncompromised. The thymus decreases in size.
The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What will be the nurse's initial action?
- A. Cover with a warm blanket.
- B. Take the patient's temperature.
- C. Elevate the head of the bed.
- D. Stop the transfusion and continue with saline.
Correct Answer: D
Rationale: Moderate reactions, resulting in fever, chills, urticaria, and wheezing, occur after the first 30 minutes of administration. In the event of a moderate reaction, stop the transfusion, continue with saline, and notify the health care provider. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance.
The nurse outlines for a patient who has asthma attacks from pollen that the process from exposure to symptoms follows a systematic sequence. Which change is the last physiologic responses of an allergic asthma attack?
- A. Release of histamine
- B. Edema
- C. Vasodilation
- D. Activation of mast cells
- E. Bronchospasm
- F. Exposure to pollen
Correct Answer: E
Rationale: The mast cells in the lungs are activated by the exposure to pollen. Histamine is released causing vasodilation, edema, and bronchospasm for the asthmatic.