Quiz 20: Immunity

Concepts For Nursing Practice

Nursing
7
Questions
0
True/False
6
Choices
1
Essay
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Questions

Q1
Free

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patients discharge planning?

Multiple Choice
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A) The mechanisms of the inflammatory response
B) Basic infection control techniques
C) The importance of wearing a face mask in public
D) Limiting contact with the general population
Answer:
B) Basic infection control techniques

Explanation:
The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.
Q2
Free

An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the childs growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for

Multiple Choice
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A) primary immunodeficiency.
B) secondary immunodeficiency.
C) cancer.
D) autoimmunity.
Answer:
A) primary immunodeficiency.

Explanation:
Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.
Q3
Free

The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation if

Multiple Choice
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A) his immune system is functioning properly.
B) he is properly vaccinated.
C) he has an infection.
D) the suppressor T-cells in his body are activated.
Answer:
A) his immune system is functioning properly.

Explanation:
Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the bodys response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body.
Q4

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she states which of the following?

Multiple Choice
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A) My body will treat the new kidney like my original kidney.
B) I will have to make sure that I avoid being around people.
C) The medications that I take will help prevent my body from attacking my new kidney.
D) My body will only have a problem with my new kidney if the donor is not directly related to me.
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Q5

The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patients respirations are 26 breaths/min with pulse 112 beats/min and weak. The nurse suspects that the patient is experiencing a(n)

Multiple Choice
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A) suppressed immune response.
B) hyperimmune response.
C) allergic reaction.
D) anaphylactic reaction.
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Q6

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse explains to the patient that the goal of medication treatments for RA is to

Multiple Choice
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A) eradicate the disease.
B) enhance immune response.
C) control inflammation.
D) manage pain.
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Q7

[Multiple Response] The parents of a newborn question the nurse about the need for vaccinations: Why does our baby need all those shots? Hes so small, and they have to cause him pain. The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.)
a. Are only required for infants
b. Are part of primary prevention for system disorders
c. Prevent the child from getting childhood diseases
d. Help protect individuals and communities
e. Are risk free
f. Are recommended by the Centers for Disease Control and Prevention (CDC)

Essay
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