Test Bank Unit 4: Understanding Medical-Surgical
Nursing 6th Edition Linda S. Williams Paula D. Hopper
Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
MULTIPLE CHOICE
1. The nurse is caring for a patient who reports enlarged, painful, and moveable preauricular
lymph nodes, postauricular lymph nodes, and cervical lymph nodes. Which does the nurse
infer from these findings?
1. Infection
2. Cancer
3. Liver failure
4. Thyroid disorder
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 6. Explain objective data that are collected when caring for a patient with a
disorder of the immune system.
Page: 286
Heading: Objective Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
Feedback
1 A patient with an infection will experience tenderness and movable lymph
nodes.
2 A patient with cancer will experience nonmovable lymph nodes.
3 These do not describe symptoms of liver disease.
4 These do not describe symptoms of thyroid disease.
PTS: 1 CON: Infection
2. The nurse is caring for a group of patients. Which patient is at highest risk for developing
systemic lupus erythematosus (SLE)?
1. An African American female
2. A Caucasian female
3. An Asian male
4. A Hispanic male
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 5. Explain subjective data that are collected when caring for a patient with a
disorder of the immune system.
Page: 309
Heading: Demographic Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Analysis (Analyzing)
, Concept: Immunity
Difficulty: Moderate
Feedback
1 This patient is at highest risk for developing SLE.
2 This patient is not as high risk as an African American female.
3 This patient is not as high risk as an African American female.
4 This patient is not as high risk as an African American female.
PTS: 1 CON: Immunity
3. The nurse is assisting a health care provider with subcutaneous immunotherapy (SCIT).
Which is a priority to have readily available?
1. Emergency equipment
2. Restraints
3. Antibiotic
4. Family contact information
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the
immune system.
Pages: 292–293
Heading: Immunotherapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Application (Applying)
Concept: Safety
Difficulty: Moderate
Feedback
1 Emergency equipment should be readily available in case of anaphylaxis.
2 The patient should not be restrained.
3 An antibiotic will not be useful in immunotherapy.
4 Although contact information for family is important, it is more important to
ensure emergency equipment is on hand.
PTS: 1 CON: Safety
4. The nurse is working in a clinic when a patient presents with shortness of breath, wheezing,
and hives. The nurse should plan to implement which order first?
1. Administer morphine IV
2. Administer epinephrine IV
3. Administer ketorolac (Toradol) IV
4. Administer furosemide (Lasix) IV
ANS: 2
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 8. Describe common therapeutic measures used for disorders of the immune
system.
Page: 297
, Heading: Allergies
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Application (Applying)
Concept: Inflammation
Difficulty: Moderate
Feedback
1 This patient is likely experiencing an anaphylactic reaction; morphine is not
administered.
2 This patient is likely experiencing an anaphylactic reaction; epinephrine will be
administered.
3 This patient is likely experiencing an anaphylactic reaction; Toradol will not be
given.
4 This patient is likely experiencing an anaphylactic reaction; Lasix may be
given to ease breathing and remove fluid, but it is not a priority.
PTS: 1 CON: Inflammation
5. The nurse is caring for a group of patients. Which patients should the nurse see first?
1. A patient with allergic rhinitis reporting frequent sneezing
2. A patient who had an anaphylactic reaction 2 days ago
3. A patient who just received an influenza vaccination
4. A patient receiving chemotherapy with a temperature of 103°F
ANS: 4
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 6. Explain objective data that are collected when caring for a patient with a
disorder of the immune system.
Page: 288
Heading: Objective Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
Feedback
1 This patient is not the highest priority.
2 This patient should be seen, but is not as high a priority as an
immunocompromised patient with a fever.
3 This patient is not a priority.
4 This patient should be seen first because he or she is immunocompromised and
has a high fever.
PTS: 1 CON: Infection
6. The nurse is caring for a patient being tested for rheumatoid arthritis. In reviewing
laboratory values, which should the nurse recognize as being diagnostic of rheumatoid
arthritis?
1. C-reactive protein = 12 mg/L
, 2. Negative rheumatoid factor
3. White blood cells (WBC) = 6,000/mm3
4. Negative antinuclear antibody (ANA) test
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the
immune system.
Page: 289
Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
Feedback
1 A normal C-reactive protein level is less than 10 mg/L; an elevated level is
present in rheumatoid arthritis, cancer, and SLE.
2 ANA and rheumatoid factor are positive in the presence of rheumatoid arthritis.
3 This is a normal WBC count, which measures immune function.
4 ANA and rheumatoid factor are positive in the presence of rheumatoid arthritis.
PTS: 1 CON: Immunity
7. The nurse is reinforcing teaching to a person who has tested positive for HIV. Which test
should the nurse explain is done to confirm the diagnosis of HIV?
1. Western blot
2. Rheumatoid factor
3. ANA
4. Immunoglobulin assay
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the
immune system.
Page: 290
Heading: Diagnostic Laboratory Tests for the Immune System
Integrated Process: Clinical Problem-Solving Process (nursing Process)
Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying)
Concept: Immunity
Difficulty: Moderate
Feedback
1 Western blot is used as a confirmation test for HIV.
2 This test is done to determine the presence of rheumatoid arthritis.
3 This test is done to determine the presence of rheumatoid arthritis.
4 Immunoglobulin assays are completed to determine the presence of an
infection.
PTS: 1 CON: Immunity
Nursing 6th Edition Linda S. Williams Paula D. Hopper
Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
MULTIPLE CHOICE
1. The nurse is caring for a patient who reports enlarged, painful, and moveable preauricular
lymph nodes, postauricular lymph nodes, and cervical lymph nodes. Which does the nurse
infer from these findings?
1. Infection
2. Cancer
3. Liver failure
4. Thyroid disorder
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 6. Explain objective data that are collected when caring for a patient with a
disorder of the immune system.
Page: 286
Heading: Objective Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
Feedback
1 A patient with an infection will experience tenderness and movable lymph
nodes.
2 A patient with cancer will experience nonmovable lymph nodes.
3 These do not describe symptoms of liver disease.
4 These do not describe symptoms of thyroid disease.
PTS: 1 CON: Infection
2. The nurse is caring for a group of patients. Which patient is at highest risk for developing
systemic lupus erythematosus (SLE)?
1. An African American female
2. A Caucasian female
3. An Asian male
4. A Hispanic male
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 5. Explain subjective data that are collected when caring for a patient with a
disorder of the immune system.
Page: 309
Heading: Demographic Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Analysis (Analyzing)
, Concept: Immunity
Difficulty: Moderate
Feedback
1 This patient is at highest risk for developing SLE.
2 This patient is not as high risk as an African American female.
3 This patient is not as high risk as an African American female.
4 This patient is not as high risk as an African American female.
PTS: 1 CON: Immunity
3. The nurse is assisting a health care provider with subcutaneous immunotherapy (SCIT).
Which is a priority to have readily available?
1. Emergency equipment
2. Restraints
3. Antibiotic
4. Family contact information
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the
immune system.
Pages: 292–293
Heading: Immunotherapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Application (Applying)
Concept: Safety
Difficulty: Moderate
Feedback
1 Emergency equipment should be readily available in case of anaphylaxis.
2 The patient should not be restrained.
3 An antibiotic will not be useful in immunotherapy.
4 Although contact information for family is important, it is more important to
ensure emergency equipment is on hand.
PTS: 1 CON: Safety
4. The nurse is working in a clinic when a patient presents with shortness of breath, wheezing,
and hives. The nurse should plan to implement which order first?
1. Administer morphine IV
2. Administer epinephrine IV
3. Administer ketorolac (Toradol) IV
4. Administer furosemide (Lasix) IV
ANS: 2
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 8. Describe common therapeutic measures used for disorders of the immune
system.
Page: 297
, Heading: Allergies
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Application (Applying)
Concept: Inflammation
Difficulty: Moderate
Feedback
1 This patient is likely experiencing an anaphylactic reaction; morphine is not
administered.
2 This patient is likely experiencing an anaphylactic reaction; epinephrine will be
administered.
3 This patient is likely experiencing an anaphylactic reaction; Toradol will not be
given.
4 This patient is likely experiencing an anaphylactic reaction; Lasix may be
given to ease breathing and remove fluid, but it is not a priority.
PTS: 1 CON: Inflammation
5. The nurse is caring for a group of patients. Which patients should the nurse see first?
1. A patient with allergic rhinitis reporting frequent sneezing
2. A patient who had an anaphylactic reaction 2 days ago
3. A patient who just received an influenza vaccination
4. A patient receiving chemotherapy with a temperature of 103°F
ANS: 4
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 6. Explain objective data that are collected when caring for a patient with a
disorder of the immune system.
Page: 288
Heading: Objective Data
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Analysis (Analyzing)
Concept: Infection
Difficulty: Moderate
Feedback
1 This patient is not the highest priority.
2 This patient should be seen, but is not as high a priority as an
immunocompromised patient with a fever.
3 This patient is not a priority.
4 This patient should be seen first because he or she is immunocompromised and
has a high fever.
PTS: 1 CON: Infection
6. The nurse is caring for a patient being tested for rheumatoid arthritis. In reviewing
laboratory values, which should the nurse recognize as being diagnostic of rheumatoid
arthritis?
1. C-reactive protein = 12 mg/L
, 2. Negative rheumatoid factor
3. White blood cells (WBC) = 6,000/mm3
4. Negative antinuclear antibody (ANA) test
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the
immune system.
Page: 289
Heading: Diagnostic Laboratory Tests for the Immune System (Table 18.4)
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Safety and Infection Control
Cognitive Level: Analysis (Analyzing)
Concept: Immunity
Difficulty: Moderate
Feedback
1 A normal C-reactive protein level is less than 10 mg/L; an elevated level is
present in rheumatoid arthritis, cancer, and SLE.
2 ANA and rheumatoid factor are positive in the presence of rheumatoid arthritis.
3 This is a normal WBC count, which measures immune function.
4 ANA and rheumatoid factor are positive in the presence of rheumatoid arthritis.
PTS: 1 CON: Immunity
7. The nurse is reinforcing teaching to a person who has tested positive for HIV. Which test
should the nurse explain is done to confirm the diagnosis of HIV?
1. Western blot
2. Rheumatoid factor
3. ANA
4. Immunoglobulin assay
ANS: 1
Chapter: Chapter 18. Immune System Function, Assessment, and Therapeutic Measures
Objective: 7. Describe nursing care provided for patients undergoing diagnostic tests for the
immune system.
Page: 290
Heading: Diagnostic Laboratory Tests for the Immune System
Integrated Process: Clinical Problem-Solving Process (nursing Process)
Client Need: SECE—Safety and Infection Control Cognitive Level: Application (Applying)
Concept: Immunity
Difficulty: Moderate
Feedback
1 Western blot is used as a confirmation test for HIV.
2 This test is done to determine the presence of rheumatoid arthritis.
3 This test is done to determine the presence of rheumatoid arthritis.
4 Immunoglobulin assays are completed to determine the presence of an
infection.
PTS: 1 CON: Immunity
