Deck 18: Assessment of Immune Function

Question 1

The nurse is providing care to a patient with a compromised immune system.Which independent nursing intervention is appropriate for the nurse to include in the patient's plan of care?

A) Recommending gene transfer therapy
B) Administering corticosteroids,per order
C) Prescribing prophylactic antibiotic therapy
D) Educating on the importance of a nutritious diet

Answer 1

Educating on the importance of a nutritious diet

Question 2

A nurse working in the emergency department (ED)is providing care for a group of patients.Which patient demonstrates a decline in immune response that typically occurs with the aging process?

A) An 88-year-old with pneumonia who has a temperature of 99.5°F.
B) A 56-year-old who has 8 mm induration at the site of a PPD skin test 72 hours earlier.
C) A 58-year-old who reports redness and itching due to a rash from contact with poison ivy.
D) A 70-year-old who has swelling and redness at the incision from an open appendectomy.

Answer 2

An 88-year-old with pneumonia who has a temperature of 99.5°F.

Question 3

Which nutritional deficiency often impacts a patient's ability to mount an immune response?

A) Proteins
B) Calcium
C) Potassium
D) Carbohydrates

Answer 3

Proteins

Question 4

The nurse is providing care to a patient who has a decreased neutrophil count and elevated hepatic enzymes.Which data in the patient's health history supports this laboratory data indicating an increased risk for infection?

A) Anorexia nervosa
B) Acute renal failure
C) Pulmonary disease
D) Cirrhosis of the liver

Question 5

Which type of immunoglobulin (Ig)is produced during an allergic reaction?

A) IgA
B) IgD
C) IgE
D) IgM

Question 6

Which nursing action is appropriate when assessing a patient's tonsils during a physical examination?

A) Asking the patient to cough several times
B) Asking the patient to open the mouth and say "ah"
C) Palpating the soft tissue of the face near the patient's nose
D) Palpating the left upper quadrant of the patient's abdomen

Question 7

The nurse is providing care to a patient who has an increased number of lymphocytes.Which explanation should the nurse provide to the patient regarding this abnormality?

A) "An elevated neutrophil count indicates your body is battling a parasitic infection."
B) "An elevated neutrophil count indicates your body is battling a bacterial infection."
C) "An elevated neutrophil count indicates your body is experiencing an allergic reaction."
D) "An elevated neutrophil count indicates your body is experiencing an adaptive immune response."

Question 8

The nurse is conducting a health history for a patient who is at risk for infection.Which question is appropriate when collecting data related to the patient's past medical history?

A) "Do you smoke cigarettes?"
B) "Are your immunizations current and up-to-date?"
C) "What type of reaction do you have with an allergy flair?"
D) "Did you have your spleen removed after your car accident?"

Question 9

A nurse is caring for a patient with who is experiencing leukocytosis.When providing care to this patient,which action by the nurse is the most appropriate?

A) Assess for source of infection
B) Assess for bleeding and bruising
C) Place the patient in reverse isolation precautions
D) Instruct the patient on the use of an electric razor and soft toothbrush

Question 10

The nurse is providing care to a patient who experienced an allergic reaction.Which leukocyte does the nurse anticipate will be elevated?

A) Basophils
B) Monocytes
C) Eosinophils
D) Neutrophils

Question 11

Which laboratory test should the nurse anticipate for a patient who reports chronic inflammation?

A) Varicella titer
B) Type and crossmatch
C) Erythrocyte sedimentation rate (ESR)
D) Complete blood count (CBC)
,with differential

Question 12

The nurse is providing care to patient who is at an increased risk for infection due to poor dietary intake,a decreased white blood cell count,and diminished neutrophil activity.Which information in the patient's health history supports the current data?

A) Anorexia nervosa
B) Acute renal failure
C) Pulmonary disease
D) Cirrhosis of the liver

Question 13

Which physiological barriers protect the patient's body against microorganisms?

A) A surgical incision
B) Occasional smoking
C) Alcoholic beverages
D) Adequate urinary output

Question 14

The nurse is teaching a new mother the immune benefits of breastfeeding her newborn.Which immunoglobulin (Ig)should the nurse include as one that is passed from mother to newborn by breast milk?

A) IgA
B) IgD
C) IgE
D) IgG

Question 15

Which scenario should the nurse provide as one in which active immunity is acquired when educating a group within the community?

A) Having measles as a child
B) Receiving an injection of gamma globulin
C) Becoming ill with tetanus and receiving tetanus toxoid
D) Receiving a rabies shot after being bitten by a rabid dog

Question 16

The nurse is providing care to a patient who had the spleen removed after a car accident.Which type of infection is this patient at an increased risk for experiencing?

A) Viral
B) Fungal
C) Parasitic
D) Bacterial

Question 17

The nurse is teaching a group of patients about first-line defense against infection.Which patient statement indicates the need for further education?

A) "The skin is a first-line defense against infection."
B) "A sneeze is a mechanical first-line defense against infection."
C) "My saliva is a biochemical first-line defense against infection."
D) "A cut with pus is a mechanical first-line defense against infection."

Question 18

The nurse is conducting a health history for a patient who is at risk for infection.Which question is appropriate when collecting data related to the current problem?

A) "Do you smoke cigarettes?"
B) "Are your immunizations current and up-to-date?"
C) "What type of reaction do you have with an allergy flair?"
D) "Did you have your spleen removed after your car accident?"

Question 19

The nurse is conducting a health history for a patient who is at risk for infection.Which question is appropriate when collecting data related to the patient's social history?

A) "Do you smoke cigarettes?"
B) "Are your immunizations current and up-to-date?"
C) "What type of reaction do you have with an allergy flair?"
D) "Did you have your spleen removed after your car accident?"

Question 20

Which question should the nurse to ask during a health history with an adolescent patient,accompanied by a parent,to determine immune status?

A) "Is your child sexually active?"
B) "Is your child planning to go to college?"
C) "Does your child smoke tobacco products?"
D) "Are your child's immunizations up-to-date?"