Chapter 54 Care of the Patient with an Immune Disorder Nursing Test Banks PDF

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Chapter 54: Care of the Patient with an Immune Disorder | Nursing Test Banks

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Chapter 54: Care of the Patient with an Immune Disorder Chapter 54: Care of the Patient with an Immune Disorder Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition MULTIPLE CHOICE 1.Which of the following 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

ANS: C 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 with residual illness. PTS: 1 DIF: Cognitive Level: Application REF: Page 1962 OBJ:1TOP:Immunocompetence KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2.An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse’s rst intervention? https://boostgrade.info/chapter-54-care-of-the-patient-with-an-immune-disorder/

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a.

Apply cool compresses to urticaria

b.

Provide oxygen per non-rebreathing mask

c.

Cover patient with a warm blanket

d.

Prepare for venipuncture for the delivery of IV medication

ANS: B Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention. PTS: 1 DIF: Cognitive Level: Application REF: Page 1971 OBJ:6TOP:Anaphylactic reaction KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3.What is the etiology of autoimmune diseases based on?

a.

Reaction to a “superantigen”

b.

Immune system producing no antibodies at all

c.

T cells destroying B cells

d.

B and T cells producing autoantibodies

ANS: D Autoimmune disorders are failures of the tolerance to “self.” B and T cells produce autoantibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish “self” protein from “foreign” protein. PTS: 1 DIF: Cognitive Level: Application REF: Page 1974 OBJ:1TOP:Autoimmune disorders KEY:Nursing Process Step: Implementation https://boostgrade.info/chapter-54-care-of-the-patient-with-an-immune-disorder/

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MSC: NCLEX: Physiological Integrity 4.A patient is admitted with a secondary immunodeciency from chemotherapy. The nursing plan of care should include provisions for:

a.

infection control.

b.

supporting self-care.

c.

nutritional education.

d.

maintaining high uid intake.

ANS: A Immune decient persons are at risk for infection and need to be protected aggressively for contagion. PTS: 1 DIF: Cognitive Level: Application REF: Page 1973 OBJ:10TOP:Immunodeciency diseases KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Eective Care Environment 5.The nurse takes into consideration that when the antigen and antibody react, the complement system is activated which:

a.

toughens the cell wall.

b.

generates more T cells.

c.

attracts phagocytes.

d.

makes the antigen resistant.

ANS: C The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes. PTS: 1 DIF: Cognitive Level: Application REF: Page 1966 OBJ:3TOP:Complement system

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KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6.How does normal aging change the immune system?

a.

Depresses bone marrow

b.

T cells become hyperactive

c.

B cells show deciencies in activity

d.

Increase in the size of the thymus

ANS: C Normal aging causes deciencies in both B and T cell activation, but the bone marrow is essentially uncompromised. The thymus decreases in size. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1966 OBJ:N/ATOP:Age-related changes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7.What would the nurse recommend for a 94-year-old home health patient with deteriorated cell-mediated immunity?

a.

Avoiding the inuenza vaccine

b.

Getting pneumonia vaccine

c.

Having skin tests for all antigens

d.

Taking large doses of beta-carotene

ANS: B As the older adult loses some of the cell-mediated immunity, especially against pneumonia and inuenza, it is recommended that they acquire the immunization. PTS: 1 DIF: Cognitive Level: Application REF: Page 1966

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OBJ:3TOP:Age-related changes KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8.A patient who works in a plant nursery and has suered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identies a need for additional teaching based on which comment?

a.

“I need to think about a change in my occupation.”

b.

“I will learn to administer epinephrine so that I will be prepared if I am stung again.”

c.

“I should wear a Medic-Alert bracelet indicating my allergy to insect stings.”

d.

“I will need to take maintenance doses of corticosteroids to prevent reactions to further stings.”

ANS: D The nurse’s responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance doses of corticosteroids because this was a short, rapid reaction. PTS: 1 DIF: Cognitive Level: Application REF: Page 1970 OBJ:5TOP:Allergic reaction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 9.What is the substance released by the T cells that stimulates the lymphocytes to attack an inammation?

a.

Lymphokine

b.

Epinephrine

c.

B cells

d.

Histamine

ANS: A Lymphokines help attract macrophages to the site of the inammation. https://boostgrade.info/chapter-54-care-of-the-patient-with-an-immune-disorder/

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PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1964 OBJ: 3 TOP: Allergic reaction KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 10.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 anti-inammatory cream to the site

ANS: B Injection of subcutaneous epinephrine should be given at the rst sign of allergy. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1967 OBJ:7TOP:Anaphylactic reaction treatment KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11.Which person is most at risk for a hypersensitivity reaction?

a.

26-year-old receiving his second desensitization injection

b.

35-year-old starting back on birth control tablets

c.

The 52-year-old started on a new series of Pyridium for cystitis

d.

The 84-year-old receiving penicillin for an annually recurring respiratory infection

ANS: D

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The 84-year-old with the deteriorated immune system is a prime candidate for a delayed hypersensitivity reaction. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1960, Box 54-4 OBJ:5TOP:Delayed hypersensitivity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12.The nurse recommends to the busy mother of three that the antihistamine fexofenadine (Allegra) would be more benecial than diphenhydramine (Benadryl) because Allegra:

a.

is inexpensive.

b.

contains a stimulant for an energy boost.

c.

does not dry out the mucous membranes.

d.

does not induce drowsiness.

ANS: D Allegra does not induce drowsiness as does Benadryl. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1969 OBJ:N/ATOP:Antihistamines KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13.The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutaneous injection of epinephrine. What eect should the nurse assure the anxious patient this will have?

a.

Cause vasodilation

b.

Produce bronchodilation

c.

Cause productive coughing

d.

Reduction of pulse rate

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ANS: B The drug epinephrine is given in the case of anaphylaxis because it is a quick-acting drug that produces bronchodilation and vasoconstriction, which relieves respiratory distress. The drug can be ordered to be repeated every 20 minutes. The patient may experience an increase in heart rate. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1970 OBJ: 3 TOP: Anaphylaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14.Health care facilities have reduced the incidence of serious latex reactions by:

a.

Having local and injectable corticosteroids on hand for employees

b.

Desensitizing sta who are allergic

c.

Supplying extra handwashing stations in the halls

d.

Using only powder-free gloves

ANS: D Powder inside gloves can become aerosolized and cause inhalant reactions. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1971 OBJ: 8 TOP: Latex allergic reaction KEY: Nursing Process Step: N/A MSC:NCLEX: Safe, Eective Care Environment 15.What should the nurse include to assess for in the plan of care for a patient undergoing plasmapheresis?

a.

Hypotension

b.

Hypersensitivity

c.

Urticaria

d.

Flank pain

ANS: A https://boostgrade.info/chapter-54-care-of-the-patient-with-an-immune-disorder/

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Hypotension occurs during plasmapheresis because of transient volume changes in the blood. PTS: 1 DIF: Cognitive Level: Application REF: Page 1975 OBJ:12TOP:Plasmapheresis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 16.A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, what should the patient receive?

a.

Larger doses each week

b.

Higher concentrations each week

c.

Increased amounts and concentrations in 6-week cycles

d.

The same amount and concentration each visit

ANS: C Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better eect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6week period. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1967 OBJ:N/ATOP:Immunotherapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17.What is the term for transplantation of tissue between members of the same species?

a.

Allograft

b.

Autograft

c.

Isograft

d.

Homograft

ANS: A

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The allograft is the transplantation of tissues between members of the same species, such as a graft for fullthickness burns. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1973 OBJ: N/A TOP: Allograft KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18.In which patient should the nurse be most concerned about immunodeciency disorder?

a.

The patient taking desensitization injections (immunotherapy)

b.

The patient on long-term radiation therapy for cancer

c.

The overweight patient

d.

The patient recently diagnosed with lupus erythematosus

ANS: B Radiation destroys lymphocytes and depletes the stem cells. Prolonged radiation depresses the bone marrow. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1974 OBJ:N/ATOP:Immunosuppression KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 19.What is the purpose of plasmapheresis in the treatment of rheumatoid arthritis?

a.

To add corticosteroids to relieve pain

b.

To remove pathologic substances present in the plasma

c.

To remove waste products such as urea and albumin

d.

To add antinuclear antibodies

ANS: B Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease.

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PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1974 OBJ:12TOP:Plasmapheresis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20.The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient received a ___________ type of immunity.

a.

Active natural

b.

Passive natural

c.

Active articial

d.

Passive articial

ANS: D When a person receives an inoculation of antibodies from another source, as with tetanus antitoxin, it is considered a passive articial immunity. PTS: 1 DIF: Cognitive Level: Application REF: Page 1960, Box 54-1 OBJ: 2 TOP: Immunity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21.Because the older adult has decreased production of saliva and gastric secretions, they are at risk for:

a.

mouth ulcers.

b.

ssures in corners of the mouth.

c.

gastrointestinal infections.

d.

bloating.

ANS: C Decient saliva and gastric secretions make the older adult prone to gastrointestinal infections. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1968 https://boostgrade.info/chapter-54-care-of-the-patient-with-an-immune-disorder/

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OBJ:N/ATOP:Age-related changes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 22.What is the major negative eect of cell-mediated immunity?

a.

Depression of bone marrow

b.

Rejection of transplanted tissue

c.

Activation of the T cells

d.

Stimulation of the B cells

ANS: B Cell-mediated immunity has the negative eect of rejection of transplanted tissue. Activation of T cells and stimulation of B cells are the positive basis of the cell-mediated immunity. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1965 OBJ:3TOP:Hypersensitivity KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23.What is B-cell proliferation dependent on?

a.

Presence of NK (natural killer) cells

b.

Complement system

c.

Antigen stimulation

d.

Lymphokines

ANS: C Antigen stimulation is the sole focus of B-cell proliferation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1964

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OBJ:3TOP:B-cell proliferation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24.What timeframe must blood be transfused within once it has been removed from refrigeration?

a.

2 hours

b.

4 hours

c.

6 hours

d.

3 hours

ANS: B Blood must be administered within 4 hours after removal from refrigeration, and blood components within 6 hours of removal. PTS: 1 DIF: Cognitive Level: Application REF: Page 1972 OBJ:9TOP:Blood products KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Eective Care Environment 25.The LPN/LVN has arrived at the patient’s bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the rst thing the nurses must do?

a.

Check to ensure that the donor and recipient numbers match according to policy

b.

Request the patient to sign the card on the packed cells

c.

Immediately administer the packed cells

d.

Check the patient’s ID bracelet and then administer the packed cells

ANS: A Donor and recipient numbers are specic and must be thoroughly checked and the patient identied with an armband.