Medical Surgical Nursing Concepts & Practice, 2nd Edition by Susan C. – Test Bank

Medical Surgical Nursing Concepts & Practice, 2nd Edition by Susan C. – Test Bank

Chapter 10: The Immune and Lymphatic Systems

MULTIPLE CHOICE

1. The nurse points out that as a result of the aging process, one change in the immune system is:
a. thickened skin.
b. reduced ciliary action.
c. thinned periosteum.
d. reduced saliva.

ANS: B
Reduced ciliary action in the respiratory and gastrointestinal tracts results in a decrease in the removal of harmful organisms.

DIF: Cognitive Level: Knowledge REF: 197-198 OBJ: 5 (theory)
TOP: Aging Immune System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse differentiates the humoral response from the cell-mediated response in that in the cell-mediated response:
a. the sensitized lymphocytes attack the cell for which they were sensitized.
b. cells produce new antibodies.
c. the response does not occur until the white blood cell (WBC) count rises.
d. there is a systemic response of fever and malaise.

ANS: A
Cell-mediated response occurs when the specifically antigen-sensitized T lymphocytes attack whole cells, infectious organisms, and nonliving matter such as pollen and dust.

DIF: Cognitive Level: Comprehension REF: 199 OBJ: 1 (theory)
TOP: Cell-Mediated Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. The nurse clarifies that the lymphocytes that actually produce either sensitized lymphocytes or antibodies are the:
a. B lymphocytes.
b. T cells.
c. suppressor T cells.
d. stem cells.

ANS: A
The B cells secrete immunoglobulins that are called antibodies.

DIF: Cognitive Level: Comprehension REF: 197 OBJ: 1 (theory)
TOP: Production of Antibodies KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

4. The nurse explains to a patient with a painful toe that the pain is related to the inflammatory response, which causes the discomfort by the:
a. swelling, which compresses nerves.
b. enzyme release, which irritates the area.
c. acidic waste from the destroyed cells.
d. heat of lysis, which affects the nerves.

ANS: A
The swelling brought on by the fluid that collects at the site compresses nerves, causing pain.

DIF: Cognitive Level: Application REF: 198 OBJ: 1 (theory)
TOP: Inflammatory Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

5. The nurse reviewing lab results notes that the C-reactive protein is elevated in the patient who had surgery 2 days ago. The nurse is aware this is an indication of:
a. impending infection.
b. possible hemorrhage.
c. a drug allergic reaction.
d. fluid deficit.

ANS: A
Since inflammation is an early response to infection, an elevation of the C-reactive protein (which elevates with inflammation) is an indicator of possible impending infection. C-reactive protein is not directly related to hemorrhage, drug reaction, or fluid deficit.

DIF: Cognitive Level: Application REF: 208 | Table 10-3
OBJ: 1 (clinical) TOP: C-Reactive Protein
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

6. The nurse is preparing a presentation on the inflammatory response. While preparing a cartoon picture of lysis, the nurse correctly draws which scenario?
a. An antibody acting through the process of neutralization
b. An individual’s arm that is red and swollen
c. A phagocyte eating an antigen
d. A cell that is originating in the bone marrow

ANS: C
Lysis is the result of phagocytosis. Phagocytes “gobble up” antigens. An antibody acting through the process of neutralization depicts production of an antitoxin. Redness and swelling of the skin surface are general characteristics of inflammation. The picture of the cell originating in the bone marrow is depicting lymphocytic cells, which are a specialized type of WBC that originates in the bone marrow.

DIF: Cognitive Level: Analysis REF: 200 OBJ: 3 (theory)
TOP: Lysis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

7. The nurse exemplifies the action of killer T cells as being like a:
a. tiger slowly stalking an antigen to devour it.
b. mad hornet flying through circulating fluids seeking and killing antigens.
c. spider waiting in a web for an antigen to get caught in it.
d. bird dog pointing to an antigen so it can be attacked by phagocytes.

ANS: B
Killer T cells move around in body fluids and react wherever they encounter the antigen.

DIF: Cognitive Level: Analysis REF: 199 | Figure 10-3
OBJ: 1 (theory) TOP: Lysis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

8. The nurse points out that the fact that humans do not contract such diseases as distemper, as dogs do, is due to the human’s _____ immunity.
a. passive
b. acquired
c. innate
d. passive natural

ANS: C
Innate immunity is based on the genetic makeup of a particular species that allows that species to be immune to specific diseases without having had the infection themselves. An example is humans don’t get distemper, but dogs do. Humans do not get hoof-and-mouth disease, but cows do.

DIF: Cognitive Level: Comprehension REF: 202 OBJ: 4 (theory)
TOP: Innate Immunity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

9. The young father tells the industrial nurse at work that he is afraid he will give his 2-week-old baby his cold. The nurse assures him that the baby is protected by _____ immunity.
a. acquired
b. passive
c. active
d. passive natural

ANS: D
Passive natural immunity is the immunity a baby gets from the mother, in utero or from breast milk, that lasts for the first several months of the baby’s life.

DIF: Cognitive Level: Comprehension REF: 202 OBJ: 4 (theory)
TOP: Immunity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

10. The nurse reminds the patient that he can be protected by passive artificial immunity by:
a. being injected with immune globulin.
b. receiving immunizations.
c. contracting the disease.
d. consuming sufficient antioxidants.

ANS: A
Immunoglobulin contains antibodies against not just one but many infectious diseases. This type of immune globulin is used when a susceptible person is exposed to or contracts a communicable disease since it enhances the immune system. Immunizations are a form of active artificially acquired immunity. Contracting the disease initiates naturally acquired immunity. Antioxidants are thought to simply boost the immune system.

DIF: Cognitive Level: Application REF: 202-203 OBJ: 4 (theory)
TOP: Passive Immunity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

11. The nurse clarifies that a vaccination or immunization gives the person a(n) _____ immunity.
a. active acquired
b. passive acquired
c. passive
d. natural

ANS: A
An immunization gives the recipient a “tiny dose” of a disease, enough to stimulate the production of antibodies and is considered active artificially acquired immunity.

DIF: Cognitive Level: Comprehension REF: 203 OBJ: 4 (theory)
TOP: Immunity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

12. The nurse cautions that long-term alcohol abuse leads to alteration in the immune system by:
a. altering the effectiveness of antibodies.
b. stimulating autoimmune activity.
c. impairing the ability of B lymphocytes to produce antibodies.
d. shortening the life of circulating antibodies.

ANS: C
Alcohol impairs the ability of B lymphocytes to produce antibodies.

DIF: Cognitive Level: Comprehension REF: 203 OBJ: 5 (theory)
TOP: Impact of Alcoholism on Immune System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

13. The industrial nurse reminds all the middle-aged employees that they should get a tetanus booster every _____ years.
a. 2
b. 4
c. 7
d. 10

ANS: D
The Centers for Disease Control and Prevention (CDC) recommends that adults get a tetanus booster every 10 years.

DIF: Cognitive Level: Comprehension REF: 203 OBJ: 6 (theory)
TOP: Tetanus Booster KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

14. The outpatient clinic nurse is collecting a health history on a 78 year-old patient who has a history of emphysema. It is most important for the nurse to advise this patient to receive which annual immunization?
a. Tetanus
b. Influenza
c. Pneumonia
d. Hepatitis B

ANS: B
The CDC recommends that older adults, people with respiratory impairment, and health care workers acquire an annual influenza immunization. A pneumonia vaccination is important for this patient, but it is not given on a yearly basis. Tetanus and hepatitis B are recommended for most individuals but are not given annually.

DIF: Cognitive Level: Application REF: 204 OBJ: 6 (theory)
TOP: Influenza Immunization KEY: Nursing Process Step: NA
MSC: NCLEX: Health Promotion and Maintenance

15. The nurse who is working in a flu immunization clinic assesses for a situation with a patient that will require a postponement of immunization, such as:
a. history of asthma.
b. taking herbal remedies such as valerian and ginkgo biloba.
c. diabetes that is poorly controlled.
d. having been given immune globulin 2 weeks ago.

ANS: D
Immune globulin will decrease the immune response to the vaccine, rendering it useless. Asthma, ginkgo biloba, and uncontrolled diabetes do not prevent an individual from receiving a flu immunization.

DIF: Cognitive Level: Application REF: 204-205 OBJ: 6 (theory)
TOP: Postponement of Immunizations KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance

16. Of the assessments made by the nurse, the one indicating the immune system is functioning to combat an abscessed tooth is:
a. anorexia.
b. purulent expectorate.
c. foul breath.
d. enlarged cervical lymph node.

ANS: D
The enlarged lymph node near to the actual infection is evidence that the B and T lymphocytes are making antibodies and the activity in the lymph node has caused it to enlarge. Anorexia, purulent expectorate, and foul breath are manifestations consistent with the presence of an abscess.

DIF: Cognitive Level: Analysis REF: 206 OBJ: 1 (clinical)
TOP: Indicators of Immune System Function
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

17. The nurse is evaluating the patient’s understanding of his new diagnosis of rheumatoid arthritis. Which statement reflects an understanding of the disease process?
a. “My body lacks an appropriate response to invading bacteria.”
b. “My body produces an immune response to my own cells and tissues.”
c. “My body immediately produces a protein that is specifically designed to fight off an antigen.”
d. My body has a delayed response in which lymphocytes attack whole cells like bacteria.”

ANS: B
When a patient has an autoimmune disease such as rheumatoid arthritis, the body produces an immune response to a “self” cell or tissue. Lacking an appropriate response is characteristic of an immune deficiency. Immediate production of a protein (an antibody) to an antigen is a normal humoral immune response. The statement involving the delayed response of lymphocytes is referred to a cell-mediated response.

DIF: Cognitive Level: Application REF: 202 OBJ: 5 (theory)
TOP: Types of Immune Responses KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance

18. The mother of a young child voices concern about immunizations for her child. The nurse’s best response to the mother’s concerns is:
a. “Immunization is generally a safe method of avoiding certain diseases and the complications that go along with these diseases.”
b. “There are no risk factors associated with immunizations, so there is no reason to worry.”
c. “I really don’t understand the thinking behind people not immunizing their children if it can prevent disease.”
d. “Recommendations of Healthy People 2020 Goal 14 is to reduce or eliminate cases of vaccine-preventable diseases, so I strongly urge you to immunize your child.”

ANS: A
This is the best response since immunizations are generally safe and do help prevent certain diseases and complications of diseases. There are risk factors, such as allergic reaction to vaccinations, so this should be discussed with the mother. The nurse should not voice personal feelings about immunization. Although increasing immunizations is a goal of Healthy People 2020, this is not a helpful response to a parent.

DIF: Cognitive Level: Analysis REF: 204 OBJ: 1 (theory)
TOP: Complement System of Proteins KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

19. Antibodies can protect the body by either destroying or inactivating a particular antigen by: (Select all that apply.)
a. mechanically harming it.
b. activating the complement system.
c. releasing chemicals that alter the environment of the antigen.
d. directly attacking the nucleus of the antigen.
e. forming organic “chains” that sweep out the antigen.

ANS: A, B, C
Antibodies destroy an antigen by mechanically harming it, activating the complement system, and releasing chemicals that alter the environment of the antigen.

DIF: Cognitive Level: Application REF: 200 OBJ: 3 (theory)
TOP: Antibody Action KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. When contrasting active and passive immunity, remember that passive immunity: (Select all that apply.)
a. lasts for several years.
b. stimulates the production of antibodies.
c. prevents further tissue damage.
d. provides temporary immunity from the disease.
e. is given by vaccination.

ANS: C, D
Passive immunity prevents further damage when a disease is already present. Passive immunity provides the protection of antibodies made by someone else. Benefits of passive immunity are usually time limited as the antibodies provided only last for a specific period. Active artificial acquired immunity is achieved through immunizations.

DIF: Cognitive Level: Analysis REF: 202-203 OBJ: 4 (theory)
TOP: Passive Immunity KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. Techniques of testing for possible allergy include: (Select all that apply.)
a. the scratch test.
b. drinking diluted solution of antigen.
c. intradermal injection.
d. dropping solution in the eye.
e. adhesive patches.

ANS: A, B, C, E
Testing for allergy in the eye is no longer done. All other options will produce an inflammatory response from the application of the antigen.

DIF: Cognitive Level: Application REF: 206 | 209 OBJ: 1 (clinical)
TOP: Allergy Testing KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

22. People that the nurse would assess as immunosuppressed would be those that are: (Select all that apply.)
a. on chemotherapy for cancer.
b. using corticosteroids.
c. pregnant at 28 weeks gestation.
d. recovering from joint replacement.
e. diagnosed with HIV.

ANS: A, B, D, E
A woman at 28 weeks gestation is not considered immunocompromised. All of the other options represent people who are immunosuppressed.

DIF: Cognitive Level: Comprehension REF: 212 OBJ: 4 (theory)
TOP: Immunosuppressed People KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance

23. The nurse caring for an immunosuppressed patient would include in the care considerations to: (Select all that apply.)
a. increase fresh fruit intake.
b. adhere to Standard Precautions.
c. avoid bringing potted plants into the patient’s room.
d. employ reverse isolation.
e. use filters on air conditioner vents.

ANS: B, C, D, E
Patients who are immunosuppressed require extended precautions which are included in the neutropenic precautions, reverse isolation or protective isolation. Fresh fruit and potted plants should be avoided because bacteria and other substances that have the potential to cause harm may be present.

DIF: Cognitive Level: Application REF: 212 OBJ: 2 (clinical)
TOP: Neutropenic Precautions KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

COMPLETION

24. The bone marrow produces a(n) _______ cell that can differentiate itself to acquire individual characteristics.

ANS:
stem
Stem cells, which are produced by the bone marrow, are capable of differentiating themselves as they mature into different cells, such as liver cells and brain cells.

DIF: Cognitive Level: Knowledge REF: 195 OBJ: 1 (theory)
TOP: Stem Cells KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

25. The nurse explains that the immediate response of a person’s body that produces an antibody is called the _____________.

ANS:
humoral response
The humoral response is the immediate response of the immune system when it recognizes an antigen and then makes antibody.

DIF: Cognitive Level: Knowledge REF: 199 OBJ: 1 (theory)
TOP: Humoral Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

26. Plasma cells are stimulated to produce large quantities of specific antibodies by ____________.

ANS:
memory cells
Memory cells reactivate the plasma cells to make specialized antibodies for the antigen that the memory cells have detected.

DIF: Cognitive Level: Comprehension REF: 200 OBJ: 1 (theory)
TOP: Memory Cells KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. Lymphoid tissue that is typically found in the ileum portion of the small bowel is called ____________.

ANS:
Peyer’s patches
Peyer’s patches help defend against ingested pathogens.

DIF: Cognitive Level: Knowledge REF: 196 OBJ: 2 (theory)
TOP: Organs and Structures KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MATCHING

Place the events of the complement system of proteins in the correct sequence.
a. Antibodies attack the antigen.
b. Break in cell wall allows salt to enter antigen cell.
c. Antigen swells and bursts.
d. Water enters the antigen cell.
e. Proteins embed in cell wall of antigen.

28. Step 1

29. Step 2

30. Step 3

31. Step 4

32. Step 5

28. ANS: A DIF: Cognitive Level: Analysis REF: 198
OBJ: 1 (theory) TOP: Complement System of Proteins KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. ANS: E DIF: Cognitive Level: Analysis REF: 198
OBJ: 1 (theory) TOP: Complement System of Proteins KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. ANS: B DIF: Cognitive Level: Analysis REF: 198
OBJ: 1 (theory) TOP: Complement System of Proteins KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

31. ANS: D DIF: Cognitive Level: Analysis REF: 198
OBJ: 1 (theory) TOP: Complement System of Proteins KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

32. ANS: C DIF: Cognitive Level: Analysis REF: 198
OBJ: 1 (theory) TOP: Complement System of Proteins KEY: Nursing Process Step: NA
MSC: NCLEX: Physiological Integrity: Physiological Adaptation