ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 35 : Assessment of Immune Function Questions
Question 1 of 5
A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this patient knows that the site of the injury will have an invasion of what?
Correct Answer: 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. Apoptosis, or programmed cell death, is the bodys way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Cytokines are the various proteins that mediate the immune response. These do not migrate to injury sites.
Question 2 of 5
A man was scratched by an old tool and developed a virulent staphylococcus infection. In the course of the mans immune response, circulating lymphocytes containing the antigenic message returned to the nearest lymph node. During what stage of the immune response did this occur?
Correct Answer: B
Rationale: The recognition stage of antigens as foreign by the immune system is the initiating event in any immune response. The body must first recognize invaders as foreign before it can react to them. In the proliferation stage, the circulating lymphocyte containing the antigenic message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. In the response stage, the differentiated lymphocytes function either in a humoral or a cellular capacity. In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects with the antigen on the surface of the foreign invader.
Question 3 of 5
A patient with cystic fibrosis has received a double lung transplant and is now experiencing signs of rejection. What is the immune response that predominates in this situation?
Correct Answer: C
Rationale: Most immune responses to antigens involve both humoral and cellular responses, although only one predominates. During transplantation rejection, the cellular response predominates over the humoral response. Neither a mitigated nor nonspecific cell response is noted in this situation.
Question 4 of 5
A patient is being treated for bacterial pneumonia. In the first stages of illness, the patients dyspnea was accompanied by a high fever. Currently, the patient claims to be feeling better and is afebrile. The patient is most likely in which stage of the immune response?
Correct Answer: D
Rationale: The immune response culminates with the effector stage, during which offending microorganisms are killed by the various actions of the immune system. The patients improvement in health status is likely the result of this final stage in the immune response.
Question 5 of 5
The nurse is providing care for a patient who has multiple sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment?
Correct Answer: A
Rationale: Clinical trials using stem cells are under way in patients with a variety of disorders having an autoimmune component, including multiple sclerosis. Immunizations and genetic engineering are not used to treat multiple sclerosis. Immunosuppression would exacerbate symptoms of MS.