Ignatavicius Chapter 16 TEST BANK

The nurse learns that the most important function of inflammation and immunity is which purpose? - correct answer Immunity and inflammation working together are critical to maintaining health, preventing disease, and repairing tissue damage. 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? - correct answer Because older adults have decreased 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. A client nurse working with an older client. What action is MOST important for preventing infections in this client? - correct answer 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 client has a leg wound that is in Stage II of the inflammatory response. For what sign or symptom does the nurse assess? - correct answer During the second stage of the inflammatory response, neutrophilia occurs, producing pus. 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? - correct answer 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. The nurse understands that which type of immunity is the longest acting? - correct answer Natural active immunity is the most effective and longest acting type of immunity. The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? - correct answer Regulator T-cells help prevent hypersensitivity to one's own cells, which is the basis for autoimmune diseases. A primary health care provider notifies the nurse that a client has a "bandemia." What action does the nurse anticipate? - correct answer A bandemia, or shift to the left, in 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. What does the nurse learn about the function of colony-stimulating factor? - correct answer Colony-stimulating factor triggers the bone marrow to shorten the time needed to produce mature WBCs from about 14 days to hours. 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 normal range. What response by the nurse is the BEST? - correct answer An age-related change in immunity is that neutrophils in the older adult are less active and therefore less effective in immunity. For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (SATA) - correct answer 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. A nurse is learning about the types of different cells involved in the inflammatory process. Which principles does the nurse learn? (SATA) 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. - correct answer 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. The nurse assesses a client for the cardinal signs of inflammation. Which signs/symptoms does this include? (SATA) A. Edema B. Pulselessness C. Pallor D. Redness E. Warmth F. Decreased function - correct answer A, D, E, F. The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function. The nurse is learning about immunoglobulins. Which principles does the nurse learn? (SATA) 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 production. E. IgM is the first antibody formed by the newly sensitized B-cell. - correct answer A, C, D, E. Immunioglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associates with antibody-mediated hypersensitivity reactions. The majority of circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B-cell is immunoglobulin M (IgM). The nurse learns that which risk factors can affect immunity? (SATA) A. Age B. Environmental factors C. Ethnicity D. Drugs