KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Select
Chapter 31: Assessment of Immune Function
16e
MULTIPLE CHOICE
1. A client has been diagnosed with breast cancer and is being treated aggressively with a
chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection
because bone marrow is unable to produce a sufficient amount of:
A. lymphocytes.
B. cytoblasts.
C. antibodies.
D. capillaries.
ANS: A
Rationale: The white blood cells involved in immunity (including lymphocytes) are produced in the
bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced
by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels.
PTS: 1 REF: p. 999 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
2. During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been
immunized for mumps, and consequently possesses:
A. acquired immunity.
B. natural immunity.
C. phagocytic immunity.
, D. humoral immunity.
ANS: A
Rationale: Acquired immunity usually develops as a result of prior exposure to an antigen, often
through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three
means of defense. The first line of defense, the phagocytic immune response, involves the WBCs that
have the ability to ingest foreign particles. A second protective response is the humoral immune
response, which begins when the B lymphocytes transform themselves into plasma cells that
manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present
at birth.
PTS: 1 REF: p. 989 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
3. A gardener sustained a deep laceration while working and requires sutures. The date of the client's last
tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus
immunization, which will allow for the release of which type of substance?
A. Antibodies
B. Antigens
C. Cytokines
D. Phagocytes
ANS: A
, Rationale: Immunizations activate the humoral immune response, culminating in antibody production.
Antigens are the substances that induce the production of antibodies. Cytokines are nonantibody
proteins secreted by helper T cells that act as intercellular mediators, as in the generation of immune
response. They attract and activate B cells, cytotoxic T cells, natural killer cells, macrophages, and
other cells of the immune system. Phagocytes are white blood cells that engulf, ingest, and destroy
foreign bodies or toxins. Immunizations do not prompt cytokine or phagocyte production.
PTS: 1 REF: p. 990 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
4. An infection control nurse is presenting an in-service reviewing the immune response. The nurse
describes the clumping effect that occurs when an antibody acts like a cross-link between two
antigens. What process is the nurse explaining?
A. Agglutination
B. Cellular immune response
C. Humoral response
D. Phagocytic immune response
ANS: A
Rationale: Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link
between two antigens. This takes place within the context of the humoral immune response, but is not
synonymous with it. Cellular immune response, the immune system's third line of defense, involves
the attack of pathogens by T-cells. The phagocytic immune response, or immune response, is the
system's first line of defense, involving white blood cells that have the ability to ingest foreign
particles.
PTS: 1 REF: p. 992 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
5. A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will
cause the client to develop which expected and desired condition?
A. Natural immunity
B. Passive acquired immunity
C. Cellular immunity
D. Mild hypersensitivity
ANS: B
Rationale: Passive/adaptive acquired immunity usually develops as a result of vaccination or
contracting a disease. Natural immunity is present at birth and provides a nonspecific response to any
foreign invader. Immunizations do not activate the process of cellular immunity. Cellular immunity is
part of the innate/natural immunity response, which involves T cells that neutralize components of the
threat within the cell itself. Hypersensitivity is infrequent, and adverse reactions (i.e., urticaria,
anaphylaxis) to vaccine administration are rare.
PTS: 1 REF: p. 989 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
6. A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess
the client for which complication of therapy?
A. Immunosuppression
B. Agranulocytosis
, C. Anemia
D. Thrombocytopenia
ANS: A
Rationale: Corticosteroids, such as prednisone, can cause immunosuppression. Corticosteroids do not
typically cause agranulocytosis, anemia, or low platelet counts. Agranulocytosis, which is a decrease
in granulocytes, a type of white blood cell, may be caused by antibiotics, antithyroid drugs, or
nonsteroidal anti-inflammatory drugs. Anemia, which is a decrease in red blood cells, may be caused
by antibiotics or nonsteroidal anti-inflammatory drugs. Thrombocytopenia, which is a decrease in
platelets, may be caused by antibiotics.
PTS: 1 REF: p. 1000 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
7. A nurse is planning the assessment of a client who is exhibiting signs and symptoms of an autoimmune
disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is
known to be higher among which group?
A. Young adults
B. Native Americans/First Nations
C. Women
D. People of Hispanic descent
ANS: C
Rationale: Many autoimmune diseases have a higher incidence in females than in males, a
phenomenon believed to be correlated with sex hormones. Sex hormones play definitive roles in
lymphocyte maturation, activation, and synthesis of antibodies and cytokines. Autoimmune disorders
in women, such as lupus and multiple sclerosis, may be linked to hormonal changes that can occur
during puberty, pregnancy, and menopause. Young adults, Native Americans/First Nations and people
of Hispanic descent are not known to have a higher incidence or prevalence of autoimmune disorders.
PTS: 1 REF: p. 996 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
8. A client has been brought to the emergency department by the parents after falling through the glass of
a patio door, sustaining a laceration. The nurse caring for this client knows that the site of the injury
will have an invasion of which type of cell?
A. Interferons
B. Phagocytic cells
C. Helper T cells
D. Cytokines
ANS: B
Rationale: Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting,
and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This
occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken
glass. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is
naturally produced by the body and is capable of activating other components of the immune system.
Helper T cells are activated on recognition of antigens and stimulate the rest of the immune system.
When activated, helper T cells secrete cytokines, which attract and activate B cells, cytotoxic T cells,
NK cells, macrophages, and other cells of the immune system. Cytokines are the various proteins that
mediate the immune response. These do not migrate to injury sites.
PTS: 1 REF: p. 989 TOP: Chapter 31: Assessment of Immune Function
NOT: Multiple Select
Chapter 31: Assessment of Immune Function
16e
MULTIPLE CHOICE
1. A client has been diagnosed with breast cancer and is being treated aggressively with a
chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection
because bone marrow is unable to produce a sufficient amount of:
A. lymphocytes.
B. cytoblasts.
C. antibodies.
D. capillaries.
ANS: A
Rationale: The white blood cells involved in immunity (including lymphocytes) are produced in the
bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced
by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels.
PTS: 1 REF: p. 999 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
2. During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been
immunized for mumps, and consequently possesses:
A. acquired immunity.
B. natural immunity.
C. phagocytic immunity.
, D. humoral immunity.
ANS: A
Rationale: Acquired immunity usually develops as a result of prior exposure to an antigen, often
through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three
means of defense. The first line of defense, the phagocytic immune response, involves the WBCs that
have the ability to ingest foreign particles. A second protective response is the humoral immune
response, which begins when the B lymphocytes transform themselves into plasma cells that
manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present
at birth.
PTS: 1 REF: p. 989 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
3. A gardener sustained a deep laceration while working and requires sutures. The date of the client's last
tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus
immunization, which will allow for the release of which type of substance?
A. Antibodies
B. Antigens
C. Cytokines
D. Phagocytes
ANS: A
, Rationale: Immunizations activate the humoral immune response, culminating in antibody production.
Antigens are the substances that induce the production of antibodies. Cytokines are nonantibody
proteins secreted by helper T cells that act as intercellular mediators, as in the generation of immune
response. They attract and activate B cells, cytotoxic T cells, natural killer cells, macrophages, and
other cells of the immune system. Phagocytes are white blood cells that engulf, ingest, and destroy
foreign bodies or toxins. Immunizations do not prompt cytokine or phagocyte production.
PTS: 1 REF: p. 990 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
4. An infection control nurse is presenting an in-service reviewing the immune response. The nurse
describes the clumping effect that occurs when an antibody acts like a cross-link between two
antigens. What process is the nurse explaining?
A. Agglutination
B. Cellular immune response
C. Humoral response
D. Phagocytic immune response
ANS: A
Rationale: Agglutination refers to the clumping effect occurring when an antibody acts as a cross-link
between two antigens. This takes place within the context of the humoral immune response, but is not
synonymous with it. Cellular immune response, the immune system's third line of defense, involves
the attack of pathogens by T-cells. The phagocytic immune response, or immune response, is the
system's first line of defense, involving white blood cells that have the ability to ingest foreign
particles.
PTS: 1 REF: p. 992 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
5. A nurse has given an 8-year-old client the scheduled vaccination for rubella. This vaccination will
cause the client to develop which expected and desired condition?
A. Natural immunity
B. Passive acquired immunity
C. Cellular immunity
D. Mild hypersensitivity
ANS: B
Rationale: Passive/adaptive acquired immunity usually develops as a result of vaccination or
contracting a disease. Natural immunity is present at birth and provides a nonspecific response to any
foreign invader. Immunizations do not activate the process of cellular immunity. Cellular immunity is
part of the innate/natural immunity response, which involves T cells that neutralize components of the
threat within the cell itself. Hypersensitivity is infrequent, and adverse reactions (i.e., urticaria,
anaphylaxis) to vaccine administration are rare.
PTS: 1 REF: p. 989 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
6. A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess
the client for which complication of therapy?
A. Immunosuppression
B. Agranulocytosis
, C. Anemia
D. Thrombocytopenia
ANS: A
Rationale: Corticosteroids, such as prednisone, can cause immunosuppression. Corticosteroids do not
typically cause agranulocytosis, anemia, or low platelet counts. Agranulocytosis, which is a decrease
in granulocytes, a type of white blood cell, may be caused by antibiotics, antithyroid drugs, or
nonsteroidal anti-inflammatory drugs. Anemia, which is a decrease in red blood cells, may be caused
by antibiotics or nonsteroidal anti-inflammatory drugs. Thrombocytopenia, which is a decrease in
platelets, may be caused by antibiotics.
PTS: 1 REF: p. 1000 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice
7. A nurse is planning the assessment of a client who is exhibiting signs and symptoms of an autoimmune
disorder. The nurse should be aware that the incidence and prevalence of autoimmune diseases is
known to be higher among which group?
A. Young adults
B. Native Americans/First Nations
C. Women
D. People of Hispanic descent
ANS: C
Rationale: Many autoimmune diseases have a higher incidence in females than in males, a
phenomenon believed to be correlated with sex hormones. Sex hormones play definitive roles in
lymphocyte maturation, activation, and synthesis of antibodies and cytokines. Autoimmune disorders
in women, such as lupus and multiple sclerosis, may be linked to hormonal changes that can occur
during puberty, pregnancy, and menopause. Young adults, Native Americans/First Nations and people
of Hispanic descent are not known to have a higher incidence or prevalence of autoimmune disorders.
PTS: 1 REF: p. 996 TOP: Chapter 31: Assessment of Immune Function
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
8. A client has been brought to the emergency department by the parents after falling through the glass of
a patio door, sustaining a laceration. The nurse caring for this client knows that the site of the injury
will have an invasion of which type of cell?
A. Interferons
B. Phagocytic cells
C. Helper T cells
D. Cytokines
ANS: B
Rationale: Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting,
and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This
occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken
glass. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is
naturally produced by the body and is capable of activating other components of the immune system.
Helper T cells are activated on recognition of antigens and stimulate the rest of the immune system.
When activated, helper T cells secrete cytokines, which attract and activate B cells, cytotoxic T cells,
NK cells, macrophages, and other cells of the immune system. Cytokines are the various proteins that
mediate the immune response. These do not migrate to injury sites.
PTS: 1 REF: p. 989 TOP: Chapter 31: Assessment of Immune Function
