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