Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Latest Version Updated 2022 )Tried, Tested & Proven. 100% Accurate the Real Deal!!!

TEST BANK FOR MEDICAL SURGICAL NURSING 10TH EDITION IGNATAVICIUS (LATEST VERSION UPDATED 2021 ) TRIED, TESTED & PROVEN. 100% ACCURATE THE REAL DEAL!!! Chapter 16: Concepts of Inflammation and Immunity Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The 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 maximum protection against infection d. Regulating the process of self-tolerance ANS: C Immunity and Inflammation working together are critical to maintaining health, preventing disease, and repairing tissue damage. When all the different parts and functions of immunity are working well, the adult is immunocompetent and has maximum protection against infection. Working together, their function is not limited to destroying bacteria before damage occurs. They do not prevent the entry of all foreign materials and immunity alone regulates the process of self-tolerance. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Inflammation, Infection control MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is assessing an older client for the presence of infection. The client’s 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 the primary health care 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 would 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 TOP: Integrated Process: Nursing Process: Assessment KEY: Inflammation, Immunity MSC: Client Needs Category: Health Promotion and Maintenance 3. A clinic nurse is working with an older client. What action is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes ANS: A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Immunity, Inflammation MSC: Client Needs Category: Health Promotion and Maintenance 4. A client has a leg wound that is in Stage II of the inflammatory response. For what sign or symptom does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site ANS: B During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Inflammation, Inflammatory response MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A nurse learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils ANS: A The B-cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B-cells. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Antibody-mediated immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive ANS: C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. “Inflammatory” is not a type of immunity. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Antibody-mediated immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T-cells c. Natural killer cells d. Regulator T-cells ANS: D Regulator T-cells help prevent hypersensitivity to one’s own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Regulator T-cells have an inhibitory action on the immune system. Cytotoxic T-cells are effective against self cells infected by parasites such as viruses or protozoa. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Cell-mediated immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A primary health care provider notifies the nurse that a client has a “bandemia.” What action does the nurse anticipate? a. Administer antibiotics. b. Place the client in isolation. c. Administer IV leukocytes. d. Obtain an immunization history. ANS: A A bandemia, or shift to the left, in the white count differential means that an acute, continuing infection has placed so much stress on the immune system that the most numerous type of neutrophil in circulation are immature, or band cells. The nurse would anticipate administering antibiotics. The client may or may not need isolation. Leukocyte infusion and immunization history are not relevant. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Immunity, Decreased immunity, Older adult risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. What does the nurse learn about the function of colony-stimulating factor? a. Triggers the bone marrow to shorten the time needed to produce mature WBCs. b. Causes capillary leak in acute inflammation. c. Responsible for creating exudate (pus) at infectious sites. d. Dilates blood vessels at the site of inflammation leading to hyperemia. ANS: A Colony-stimulating factor triggers the bone marrow to shorten the time needed to produce mature WBCs from about 14 days to hours. Increased blood flow to the local area of inflammation produces hyperemia, or redness. Exudate is formed by neutrophils and consists of dead WBCs, necrotic tissue, and fluids that escape from damaged cells. Histamine, serotonin, and kinins dilate arterioles leading to redness and warmth. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Immunity, Older adult risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The older client’s adult child questions the nurse as to why the client is at higher risk for infection when the client’s white cell count is within the normal range. What response by the nurse is best? a. “The white cell count does not tell us everything about immunity.” b. “White blood cells are less active in older people so they are not as efficient.” c. “Older people typically have poor nutrition which makes them prone to infection.” d. “As one ages, immunoglobulins cease to be produced in response to illness.” ANS: B An age-related change in immunity is that neutrophils in the older adult are less active and therefore less effective in immunity. The white blood cell count is not the only thing that can inform about immunity, but this response is too vague to be useful. Many older adults do have poor nutrition that does affect immunity, but this is not true for everyone and the stem does not contain information stating that is problematic for this older adult. Immunoglobulins do not cease to be produced with age. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Immunity, Older adult risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells ANS: A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Inflammation MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis. ANS: B, C, D, E Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Inflammation, Immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth f. Decreased function ANS: A, D, E, F The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Inflammation, Immunity, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. Which are steps in the process of making an -specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization f. Production ANS: A, B, D, E, F The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Antibody-mediated immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is learning about immunoglobulins. . Which principles does the nurse learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B-cell. ANS: A, C, D, E Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B-cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Antibodies MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse learns that which risk factors can affect immunity? (Select all that apply.) a. Age b. Environmental factors c. Ethnicity d. Drugs e. Nutritional status ANS: A, B, D, E Immunity changes during an adult’s life as a result of nutritional status, environmental conditions, drugs, disease, and age. Immunity is most efficient in young adults and older adults have decreased immune function. Ethnicity does not affect immunity. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Older adult risk factors MSC: Client Needs Category: Health Promotion and 7. The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.) a. Higher risk for respiratory tract and genitourinary infections. b. May not have a fever with severe infection. c. Show expected changes in white blood cell counts. d. Should receive influenza, pneumococcal, and shingles vaccinations. e. Skin tests for tuberculosis may be falsely negative. f. Booster vaccinations are not likely needed as one ages. ANS: A, B, D, E Immunity changes during an adult’s life and older adults have decreased immune function. The number and function of neutrophils and macrophages are reduced leading to reduced response to infection and injury, such as temperature elevation. The usual response of an increased white blood cell count is delayed or absent. Older adults are less able to make new antibodies in response to the presence of new antigens requiring repeat vaccinations and immunizations. Skin tests for tuberculosis may be falsely negative and there is an increased risk for bacterial and fungal infections due to the decreased number of circulating T-lymphocytes. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Older adult risk factors MSC: Client Needs Category: Health Promotion and Maintenance 8. A nurse is studying the functions of specific leukocytes. Which leukocytes are matched correctly with their function? (Select all that apply.) a. Monocyte: matures into a macrophage. b. Basophil: releases vasoactive amines during an allergic reaction. c. Plasma cell: secretes immunoglobulins in response to the presence of a specific antigen. d. Cytotoxic T-cells: attacks and destroys ingested poisons and toxins. e. Natural killer cell: nonselectively attacks non-self cells. f. Regulator T-cells: become sensitized for self-recognition in the bone marrow. ANS: A, C, E Monocytes mature into macrophages, plasma cells secrete immunoglobulin in the presence of specific antigens, and natural killer cells nonselectively attack non-self cells. Basophils release histamines, kinins, and heparin in areas of tissue damage. Cytotoxic T-cells selectively attack and destroy non-self cells, including virally infected cells, grafts, and transplanted organs. Regulator T-cells become sensitized for self-recognition in the thymus. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Leukocytes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A nurse is studying the function of immunoglobulins. Which immunoglobulins are correctly matched to their function? (Select all that apply.) a. IgA: most responsible for preventing infection in the respiratory tracts, the GI tract, and the genitourinary tract. b. IgD: provides protection against parasite infestations, especially helminths. c. IgE: associated with antibody-mediated immediate hypersensitivity reactions. d. IgG: activates classic complement pathway and enhances neutrophil and macrophage actions. e. IgM: first antibody formed by a newly sensitized B-lymphocyte plasma cell. ANS: A, C, D, E All options are true except IgD acts as a B-cell antigen receptor. IgE provides protection against parasite infestations, especially helminths. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Immunoglobulins MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The nurse caring for clients assesses their daily laboratory profiles. Which lab results are considered to be in the normal range? (Select all that apply.) a. Segmented neutrophils: 68% b. Bands: 19% c. Monocytes: 12% d. Lymphocytes: 38% e. Eosinophils: 2% f. Basophils: 1% ANS: A, D, E, F The normal range for segmented neutrophils is 55% to 70%. The normal range for bands is 5%. The normal range for monocytes is 2% to 8%. The normal range for lymphocytes is 20% to 40%. The normal range for eosinophils is 1% to 4%. The normal range for basophils is 0.5% to 1%. a. b. c. d. e. f.