RNSG 1533 EXAM 5 COMFORT/IMMUNITY
QUESTIONS & VERIFIED ANSWERS
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 patient's discharge
planning?
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 - Answers - ANS: B
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.
An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10
months. The physician notes that the child's 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 which condition?
a. Primary immunodeficiency
b. Secondary immunodeficiency
c. Cancer
d. Autoimmunity - Answers - ANS: A
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.
,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 12-24 hours post operation dependent on which condition?
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. - Answers - ANS: A
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 body's response to intentional tissue impairment. The redness and swelling at the
incision site in the first 12-24 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.
While caring for a patient preparing for a kidney transplant, the nurse knows that the
patient understands teaching on immunosuppression when she makes which
statement?
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." - Answers - ANS: C
Immunosuppressant therapy is initiated to inhibit optimal immune response. This is
necessary in the case of transplantation, because the normal immune response would
cause the body to recognize the new tissue as foreign and attack it. The body will
identify the new kidney as foreign and will not treat it as the original kidney. While
patients with transplants must be careful about exposure to others, especially those who
are or might be ill, and practice adequate and consistent infection control techniques,
they don't have to avoid people or social interaction. The new kidney brings foreign cells
regardless of relationship between donor and recipient.
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 patient's
respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects
that the patient is experiencing which condition?
a. Suppressed immune response
b. Hyperimmune response
c. Allergic reaction
d. Anaphylactic reaction - Answers - ANS: D
, The patient is exhibiting signs and symptoms of an anaphylactic reaction to the
medication. These signs and symptoms during administration of a medication do not
correspond to a suppressed immune response but a type of hyperimmune response.
While the patient is experiencing a hyperimmune response, the signs and symptoms
allow for a more specific response. While the patient is experiencing an allergic
reaction, the signs and symptoms presented in the scenario allow for a more specific
response.
The nurse is preparing to administer medications to a patient with rheumatoid arthritis
(RA). The nurse should explain which goal of treatment to the patient?
a. Eradicate the disease
b. Enhance immune response
c. Control inflammation
d. Manage pain - Answers - ANS: C
Medications for RA are intended to control the inflammation that results from the body's
hyperimmune response. Autoimmune diseases like RA are chronic and currently have
no curative treatments. Autoimmune diseases like RA are caused by hyperimmune
response. The immune system needs to be suppressed, not enhanced. While the
medications used for RA might help with pain management, the goal of medication
intervention is to manage the inflammation.
The parents of a newborn question the nurse about the need for vaccinations: "Why
does our baby need all those shots? He's 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) -
Answers - ANS: B, D, F
Immunizations are considered part of primary prevention, help protect individuals from
contracting specific diseases and from spreading them to the community at large, and
are
recommended by the CDC. Immunizations are recommended for people at various
ages from infants to older adults. Vaccination does not guarantee that the recipient
won't get the
disease, but it decreases the potential to contract the illness. No medication is risk free.
The nurse cares for a patient infected with human immunodeficiency virus (HIV) who
has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic
measures will the nurse include in the plan of care (select all that apply)?
a. Hepatitis B vaccine
b. Pneumococcal vaccine
c. Influenza virus vaccine
QUESTIONS & VERIFIED ANSWERS
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 patient's discharge
planning?
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 - Answers - ANS: B
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.
An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10
months. The physician notes that the child's 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 which condition?
a. Primary immunodeficiency
b. Secondary immunodeficiency
c. Cancer
d. Autoimmunity - Answers - ANS: A
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.
,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 12-24 hours post operation dependent on which condition?
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. - Answers - ANS: A
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 body's response to intentional tissue impairment. The redness and swelling at the
incision site in the first 12-24 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.
While caring for a patient preparing for a kidney transplant, the nurse knows that the
patient understands teaching on immunosuppression when she makes which
statement?
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." - Answers - ANS: C
Immunosuppressant therapy is initiated to inhibit optimal immune response. This is
necessary in the case of transplantation, because the normal immune response would
cause the body to recognize the new tissue as foreign and attack it. The body will
identify the new kidney as foreign and will not treat it as the original kidney. While
patients with transplants must be careful about exposure to others, especially those who
are or might be ill, and practice adequate and consistent infection control techniques,
they don't have to avoid people or social interaction. The new kidney brings foreign cells
regardless of relationship between donor and recipient.
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 patient's
respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects
that the patient is experiencing which condition?
a. Suppressed immune response
b. Hyperimmune response
c. Allergic reaction
d. Anaphylactic reaction - Answers - ANS: D
, The patient is exhibiting signs and symptoms of an anaphylactic reaction to the
medication. These signs and symptoms during administration of a medication do not
correspond to a suppressed immune response but a type of hyperimmune response.
While the patient is experiencing a hyperimmune response, the signs and symptoms
allow for a more specific response. While the patient is experiencing an allergic
reaction, the signs and symptoms presented in the scenario allow for a more specific
response.
The nurse is preparing to administer medications to a patient with rheumatoid arthritis
(RA). The nurse should explain which goal of treatment to the patient?
a. Eradicate the disease
b. Enhance immune response
c. Control inflammation
d. Manage pain - Answers - ANS: C
Medications for RA are intended to control the inflammation that results from the body's
hyperimmune response. Autoimmune diseases like RA are chronic and currently have
no curative treatments. Autoimmune diseases like RA are caused by hyperimmune
response. The immune system needs to be suppressed, not enhanced. While the
medications used for RA might help with pain management, the goal of medication
intervention is to manage the inflammation.
The parents of a newborn question the nurse about the need for vaccinations: "Why
does our baby need all those shots? He's 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) -
Answers - ANS: B, D, F
Immunizations are considered part of primary prevention, help protect individuals from
contracting specific diseases and from spreading them to the community at large, and
are
recommended by the CDC. Immunizations are recommended for people at various
ages from infants to older adults. Vaccination does not guarantee that the recipient
won't get the
disease, but it decreases the potential to contract the illness. No medication is risk free.
The nurse cares for a patient infected with human immunodeficiency virus (HIV) who
has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic
measures will the nurse include in the plan of care (select all that apply)?
a. Hepatitis B vaccine
b. Pneumococcal vaccine
c. Influenza virus vaccine
