Chapter 15: Care of the Patient with an Immune Disorder
MULTIPLE CHOICE
1. Which of the following is an example of immunocompetence?
a. A child that is immune to measles because of an inoculation
b. A person who has seasonal allergies every fall
c. When the symptoms of a common cold disappear in 1 day
d. A neonate having a natural immunity from maternal antibodies
ANS: C
Immunocompetence is demonstrated by the immune system responding appropriately to a
foreign stimulus and the body’s integrity is maintained as with cold symptoms that resolve
with residual illness.
DIF: Cognitive Level: Application REF: Page 737 OBJ: 1
TOP: Immunocompetence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. An anxious patient enters the emergency room with angioedema of the lips and tongue,
dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be
the nurse’s first intervention?
a. Apply cool compresses to urticaria
b. Provide oxygen per non-rebreathing mask
c. Cover patient with a warm blanket
d. Prepare for venipuncture for the delivery of IV medication
ANS: B
Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly
and the patient may have to be intubated. Covering the patient with a warm blanket is not
wrong, but not an initial intervention.
DIF: Cognitive Level: Application REF: Page 746 OBJ: 6
TOP: Anaphylactic reaction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. What is the etiology of autoimmune diseases based on?
a. Reaction to a “superantigen”
b. Immune system producing no antibodies at all
c. T cells destroying B cells
d. B and T cells producing autoantibodies
ANS: D
Autoimmune disorders are failures of the tolerance to “self.” B and T cells produce
autoantibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be
described as an immune attack on the self and result from the failure to distinguish “self”
protein from “foreign” protein.
DIF: Cognitive Level: Application REF: Page 749 OBJ: 1
TOP: Autoimmune disorders KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
, 4. A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing
plan of care should include provisions for:
a. infection control.
b. supporting self-care.
c. nutritional education.
d. maintaining high fluid intake.
ANS: A
Immune deficient persons are at risk for infection and need to be protected aggressively for
contagion.
DIF: Cognitive Level: Application REF: Page 748 OBJ: 10
TOP: Immunodeficiency diseases KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
5. The nurse takes into consideration that when the antigen and antibody react, the complement
system is activated which:
a. toughens the cell wall.
b. generates more T cells.
c. attracts phagocytes.
d. makes the antigen resistant.
ANS: C
The complement system is a group of plasma proteins that are dormant until there is an
antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes.
DIF: Cognitive Level: Application REF: Page 741 OBJ: 3
TOP: Complement system KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. How does normal aging change the immune system?
a. Depresses bone marrow
b. T cells become hyperactive
c. B cells show deficiencies in activity
d. Increase in the size of the thymus
ANS: C
Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is
essentially uncompromised. The thymus decreases in size.
DIF: Cognitive Level: Analysis REF: Page 741 OBJ: N/A
TOP: Age-related changes KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
7. What would the nurse recommend for a 94-year-old home health patient with deteriorated
cell-mediated immunity?
a. Avoiding the influenza vaccine
b. Getting pneumonia vaccine
c. Having skin tests for all antigens
d. Taking large doses of beta-carotene
MULTIPLE CHOICE
1. Which of the following is an example of immunocompetence?
a. A child that is immune to measles because of an inoculation
b. A person who has seasonal allergies every fall
c. When the symptoms of a common cold disappear in 1 day
d. A neonate having a natural immunity from maternal antibodies
ANS: C
Immunocompetence is demonstrated by the immune system responding appropriately to a
foreign stimulus and the body’s integrity is maintained as with cold symptoms that resolve
with residual illness.
DIF: Cognitive Level: Application REF: Page 737 OBJ: 1
TOP: Immunocompetence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. An anxious patient enters the emergency room with angioedema of the lips and tongue,
dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be
the nurse’s first intervention?
a. Apply cool compresses to urticaria
b. Provide oxygen per non-rebreathing mask
c. Cover patient with a warm blanket
d. Prepare for venipuncture for the delivery of IV medication
ANS: B
Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly
and the patient may have to be intubated. Covering the patient with a warm blanket is not
wrong, but not an initial intervention.
DIF: Cognitive Level: Application REF: Page 746 OBJ: 6
TOP: Anaphylactic reaction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. What is the etiology of autoimmune diseases based on?
a. Reaction to a “superantigen”
b. Immune system producing no antibodies at all
c. T cells destroying B cells
d. B and T cells producing autoantibodies
ANS: D
Autoimmune disorders are failures of the tolerance to “self.” B and T cells produce
autoantibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be
described as an immune attack on the self and result from the failure to distinguish “self”
protein from “foreign” protein.
DIF: Cognitive Level: Application REF: Page 749 OBJ: 1
TOP: Autoimmune disorders KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
, 4. A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing
plan of care should include provisions for:
a. infection control.
b. supporting self-care.
c. nutritional education.
d. maintaining high fluid intake.
ANS: A
Immune deficient persons are at risk for infection and need to be protected aggressively for
contagion.
DIF: Cognitive Level: Application REF: Page 748 OBJ: 10
TOP: Immunodeficiency diseases KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
5. The nurse takes into consideration that when the antigen and antibody react, the complement
system is activated which:
a. toughens the cell wall.
b. generates more T cells.
c. attracts phagocytes.
d. makes the antigen resistant.
ANS: C
The complement system is a group of plasma proteins that are dormant until there is an
antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes.
DIF: Cognitive Level: Application REF: Page 741 OBJ: 3
TOP: Complement system KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. How does normal aging change the immune system?
a. Depresses bone marrow
b. T cells become hyperactive
c. B cells show deficiencies in activity
d. Increase in the size of the thymus
ANS: C
Normal aging causes deficiencies in both B and T cell activation, but the bone marrow is
essentially uncompromised. The thymus decreases in size.
DIF: Cognitive Level: Analysis REF: Page 741 OBJ: N/A
TOP: Age-related changes KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
7. What would the nurse recommend for a 94-year-old home health patient with deteriorated
cell-mediated immunity?
a. Avoiding the influenza vaccine
b. Getting pneumonia vaccine
c. Having skin tests for all antigens
d. Taking large doses of beta-carotene
