Chapter 17: Inflammation and Immunity Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9edition

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