HEALTH CARE
Chapter 17: Inflammation and Immunity
MULTIPLE CHOICE
1. The student nurse learns that the most important function of inflammation and immunity is which
purpose?
a. Destroying bacteria before damage occurs
b. Preventing any entry of foreign material
c. Providing protection against invading organisms
d. Regulating the process of self-tolerance
ANS: C
The purpose of inflammation and immunity is to provide protection to the body against invading
organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or
neutralize the
offending agents. The cells of the immune system are the only cells that can distinguish self from non-
self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign
invaders, and
regulating self-tolerance. DIF: Remembering/Knowledge REF: 289
KEY: Immunity| inflammation| infection control
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F
(36.4 C). What response by the nurse is best?
a. Assess the client for more specific signs.
b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request
that the provider order blood cultures.
ANS: A
Because older adults have decreased immune function, including reduced neutrophil function, fever may
not
be present during an episode of infection. The nurse should assess the client for specific signs of
infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures
may or may not be
needed depending on the results of further assessment. DIF: Applying/Application REF: 291
KEY: Infection| inflammation| immunity| older adult| nursing assessment
,MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
3. A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most
important?
a. Avoid large crowds and people who are ill.
b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You
have a higher risk of developing cancer.
ANS: A
Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large
crowds
and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take
medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin
inhibitor
category, such as tacrolimus (Prograf). DIF: Understanding/Comprehension REF: 301
KEY: Inflammation| immunity| infection control| client teaching
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A clinic nurse is working with an older client. What assessment is most important for preventing
infections in this client?
a. Assessing vaccination records for booster shot needs
b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes
ANS: A
Older adults may have insufficient antibodies that have already been produced against microbes to
which they
have been exposed. Therefore, older adults need booster shots for many vaccinations they received as
younger
people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations. DIF:
Understanding/Comprehension REF: 291
KEY: Immunity| inflammation| older adult| vaccinations
,MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
5. A client has a leg wound that is in the second stage of the inflammatory response. For what
manifestation
does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
ANS: B
During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor
(redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process. DIF:
Remembering/Knowledge REF: 295
KEY: Inflammation| immunity| inflammatory response| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nursing student learning about antibody-mediated immunity learns that the cell with the most
direct role in
this process begins development in which tissue or organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils
ANS: A
The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow.
These
cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells. DIF:
Remembering/Knowledge REF: 295
KEY: Immunity| inflammation| antibody-mediated immunity| B cell| bone marrow
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
, 7. The nurse understands that which type of immunity is the longest acting?
a. Artificial active
b. Inflammatory
c. Natural active
d. Natural passive
ANS: C
Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural
passive do not last as long.
8. The nurse working with clients who have autoimmune diseases understands that what component of
cell- mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T cells
c. Natural killer cells
d. Suppressor T cells
ANS: D
Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune
disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells
have direct
cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an
inhibitory
action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such
as
viruses or protozoa. DIF: Remembering/Knowledge REF: 296
KEY: Immunity| inflammation| cell-mediated immunity
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A client has been on dialysis for many years and now is receiving a kidney transplant. The client
experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
a. Dialysis
b. High-dose steroid administration
Chapter 17: Inflammation and Immunity
MULTIPLE CHOICE
1. The student nurse learns that the most important function of inflammation and immunity is which
purpose?
a. Destroying bacteria before damage occurs
b. Preventing any entry of foreign material
c. Providing protection against invading organisms
d. Regulating the process of self-tolerance
ANS: C
The purpose of inflammation and immunity is to provide protection to the body against invading
organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or
neutralize the
offending agents. The cells of the immune system are the only cells that can distinguish self from non-
self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign
invaders, and
regulating self-tolerance. DIF: Remembering/Knowledge REF: 289
KEY: Immunity| inflammation| infection control
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F
(36.4 C). What response by the nurse is best?
a. Assess the client for more specific signs.
b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request
that the provider order blood cultures.
ANS: A
Because older adults have decreased immune function, including reduced neutrophil function, fever may
not
be present during an episode of infection. The nurse should assess the client for specific signs of
infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures
may or may not be
needed depending on the results of further assessment. DIF: Applying/Application REF: 291
KEY: Infection| inflammation| immunity| older adult| nursing assessment
,MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
3. A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most
important?
a. Avoid large crowds and people who are ill.
b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You
have a higher risk of developing cancer.
ANS: A
Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large
crowds
and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take
medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin
inhibitor
category, such as tacrolimus (Prograf). DIF: Understanding/Comprehension REF: 301
KEY: Inflammation| immunity| infection control| client teaching
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A clinic nurse is working with an older client. What assessment is most important for preventing
infections in this client?
a. Assessing vaccination records for booster shot needs
b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes
ANS: A
Older adults may have insufficient antibodies that have already been produced against microbes to
which they
have been exposed. Therefore, older adults need booster shots for many vaccinations they received as
younger
people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations. DIF:
Understanding/Comprehension REF: 291
KEY: Immunity| inflammation| older adult| vaccinations
,MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance
5. A client has a leg wound that is in the second stage of the inflammatory response. For what
manifestation
does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
ANS: B
During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor
(redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process. DIF:
Remembering/Knowledge REF: 295
KEY: Inflammation| immunity| inflammatory response| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nursing student learning about antibody-mediated immunity learns that the cell with the most
direct role in
this process begins development in which tissue or organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils
ANS: A
The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow.
These
cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells. DIF:
Remembering/Knowledge REF: 295
KEY: Immunity| inflammation| antibody-mediated immunity| B cell| bone marrow
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
, 7. The nurse understands that which type of immunity is the longest acting?
a. Artificial active
b. Inflammatory
c. Natural active
d. Natural passive
ANS: C
Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural
passive do not last as long.
8. The nurse working with clients who have autoimmune diseases understands that what component of
cell- mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T cells
c. Natural killer cells
d. Suppressor T cells
ANS: D
Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune
disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells
have direct
cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an
inhibitory
action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such
as
viruses or protozoa. DIF: Remembering/Knowledge REF: 296
KEY: Immunity| inflammation| cell-mediated immunity
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A client has been on dialysis for many years and now is receiving a kidney transplant. The client
experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
a. Dialysis
b. High-dose steroid administration
