Nur 138 Exam 1 Questions With Correct
Answers
What |is |the |normal |immune |response?
Immune |system |is |activated |by |external |agents
Microorganisms, |minor |injuries, |major |injuries
Response |may |be |specific |or |nonspecific
Nonspecific |responses |- |prevent |or |limit |the |entry |of |invaders |into |the |body
Inflammation
Specific |immune |response |- |immune |response |designed |to |target |a |specific |antigen
identify |changes |in |the |immune |response |that |occur |with |aging
-Immune |function |declines |with |age
-More |prone |to |infections
-Poor |response |to |immunizations
-T |cells |are |less |responsive
--Thymus |stops |working |by |puberty |b/c |all |the |T |cells |are |made
-B |cells |produce |less |antibodies
-Poor |nutrition
-Immune |system |reacts |slowly
-Delayed |inflammatory |response
-Thinner |skin
-Decreased |phagocytosis
list |diagnostic |testing |to |support |a |reaction |to |a |specific |antigen
-Skin |testing |for |allergens
Intradermal |injections |or |skin |pricks
-Blood |allergy |test |(IgE |antibody |test)
-Specific |allergens |are |mixed |with |blood |samples
-Enzyme |immunoassay |(EIA)
Immunoglobulins
Western |Blot |Test
Enzyme-linked |immunosorbent |assay |(ELISA)
-Rapid |HIV |test
-CBC
Independent |nursing |actions |for |a |client |with |a |compromised |immune |system
,Provide |patient |education
Proper |nutrition
Exercise
Stress |management/reduction
Encourage |immunizations
Monitor |for |signs |of |infection
Health |history
Assess |sleep |patterns
Care |of |central |venous |catheter
-sterile |technique
-inserted |into |large |veins |in |central |venous |system |for |admin |of: |IV |fluids, |blood |products, |
chemo, |dialysis, |parenteral |nutrition, |meds
-can |be |internal |jugular |vein, |subclavian, |brachial, |femoral |veins |or |implanted |under |the |skin
-pt |education:
identify |assessment |findings |indicative |of |a |systemic |reaction |to |inflammation
Heat |- |increased |local |or |systemic |temperature
Altered |oxygenation
Infection
Edema
Anaphylaxis
Urticaria
Angioedema
Impaired |breathing
Air |hunger, |stridor, |and |wheezing
Impaired |tissue |perfusion
Hypotension
Nursing |care |of |client |with |anaphylactic |shock
Establish |airway |clearance
Place |in |fowler's |or |high |fowler's |position
Administer |epinephrine |immediately
SQ |or |IV |depending |on |the |severity
Provide |calm |reassurance
Administer |O2 |via |nasal |cannula |at |2-4L/min
Administer |SQ |epinephrine
Administer |diphenhydramine |via |IV
, Insert |a |nasopharyngeal |or |oropharyngeal |airway |and |arrange |for |immediate |intubation |as |
needed.
Comfort |measures
Monitor |cardiac |status
Monitor |vital |signs
Monitor |LOC
Assess |skin |color, |temp, |capillary |refill, |edema
Administer |warmed |IV |solutions
Insert |catheter |and |monitor |urine |output
Reduce |risk |of |injury
Identify |the |risk |factors |for |developing |infection
-Being |very |young |or |very |elderly
-People |who |are |immunocompromised
-Infants
(Short |gestation
Low |birth |weight
Bacterial |sepsis)
-Person |already |has |a |chronic |illness
-Exposure |to |unsafe |and |unsanitary |conditions
Describe |nursing |actions |to |decrease |risk |of |infections
Hand |hygiene
Standard |precautions
Immunizations
Screenings
Nutrition |and |fluids
common |methods |of |infection |transmission |in |adults
Sexual |intercourse
Kissing
Drug |use
Coughing
Sneezing
Not |washing |hands
Identify |and |apply |the |appropriate |isolation |precautions |based |on |condition/illness
Answers
What |is |the |normal |immune |response?
Immune |system |is |activated |by |external |agents
Microorganisms, |minor |injuries, |major |injuries
Response |may |be |specific |or |nonspecific
Nonspecific |responses |- |prevent |or |limit |the |entry |of |invaders |into |the |body
Inflammation
Specific |immune |response |- |immune |response |designed |to |target |a |specific |antigen
identify |changes |in |the |immune |response |that |occur |with |aging
-Immune |function |declines |with |age
-More |prone |to |infections
-Poor |response |to |immunizations
-T |cells |are |less |responsive
--Thymus |stops |working |by |puberty |b/c |all |the |T |cells |are |made
-B |cells |produce |less |antibodies
-Poor |nutrition
-Immune |system |reacts |slowly
-Delayed |inflammatory |response
-Thinner |skin
-Decreased |phagocytosis
list |diagnostic |testing |to |support |a |reaction |to |a |specific |antigen
-Skin |testing |for |allergens
Intradermal |injections |or |skin |pricks
-Blood |allergy |test |(IgE |antibody |test)
-Specific |allergens |are |mixed |with |blood |samples
-Enzyme |immunoassay |(EIA)
Immunoglobulins
Western |Blot |Test
Enzyme-linked |immunosorbent |assay |(ELISA)
-Rapid |HIV |test
-CBC
Independent |nursing |actions |for |a |client |with |a |compromised |immune |system
,Provide |patient |education
Proper |nutrition
Exercise
Stress |management/reduction
Encourage |immunizations
Monitor |for |signs |of |infection
Health |history
Assess |sleep |patterns
Care |of |central |venous |catheter
-sterile |technique
-inserted |into |large |veins |in |central |venous |system |for |admin |of: |IV |fluids, |blood |products, |
chemo, |dialysis, |parenteral |nutrition, |meds
-can |be |internal |jugular |vein, |subclavian, |brachial, |femoral |veins |or |implanted |under |the |skin
-pt |education:
identify |assessment |findings |indicative |of |a |systemic |reaction |to |inflammation
Heat |- |increased |local |or |systemic |temperature
Altered |oxygenation
Infection
Edema
Anaphylaxis
Urticaria
Angioedema
Impaired |breathing
Air |hunger, |stridor, |and |wheezing
Impaired |tissue |perfusion
Hypotension
Nursing |care |of |client |with |anaphylactic |shock
Establish |airway |clearance
Place |in |fowler's |or |high |fowler's |position
Administer |epinephrine |immediately
SQ |or |IV |depending |on |the |severity
Provide |calm |reassurance
Administer |O2 |via |nasal |cannula |at |2-4L/min
Administer |SQ |epinephrine
Administer |diphenhydramine |via |IV
, Insert |a |nasopharyngeal |or |oropharyngeal |airway |and |arrange |for |immediate |intubation |as |
needed.
Comfort |measures
Monitor |cardiac |status
Monitor |vital |signs
Monitor |LOC
Assess |skin |color, |temp, |capillary |refill, |edema
Administer |warmed |IV |solutions
Insert |catheter |and |monitor |urine |output
Reduce |risk |of |injury
Identify |the |risk |factors |for |developing |infection
-Being |very |young |or |very |elderly
-People |who |are |immunocompromised
-Infants
(Short |gestation
Low |birth |weight
Bacterial |sepsis)
-Person |already |has |a |chronic |illness
-Exposure |to |unsafe |and |unsanitary |conditions
Describe |nursing |actions |to |decrease |risk |of |infections
Hand |hygiene
Standard |precautions
Immunizations
Screenings
Nutrition |and |fluids
common |methods |of |infection |transmission |in |adults
Sexual |intercourse
Kissing
Drug |use
Coughing
Sneezing
Not |washing |hands
Identify |and |apply |the |appropriate |isolation |precautions |based |on |condition/illness
