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 patient is being treated for cancer and the nurse has identified the nursing diagnosis of Risk for Infection Due to Protein Losses. Protein losses inhibit immune response in which of the following ways?
Correct Answer: D
Rationale: Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. This specific nutritional deficit does not cause T-cell mutation, an increase in the production of interferons, or apoptosis of cytokines.
Question 2 of 5
A patient is vigilant in her efforts to take good care of herself but is frustrated by her recent history of upper respiratory infections and influenza. What aspect of the patients lifestyle may have a negative effect on immune response?
Correct Answer: A
Rationale: Rigorous exercise or competitive exercise usually considered a positive lifestyle factor can be a physiologic stressor and cause negative effects on immune response. The patients habits around diet and sleep do not present obvious threats to immune function.
Question 3 of 5
The nurse is assessing a clients risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity?
Correct Answer: B
Rationale: Stress is a psychoneuroimmunologic factor that is known to depress the immune response. Use of beta blockers, a family history of cancer, and a prior PE are significant assessment findings, but none represents an immediate threat to immune function.
Question 4 of 5
The nurse is completing a focused assessment addressing a patients immune function. What should the nurse prioritize in the physical assessment?
Correct Answer: D
Rationale: During the assessment of immune function, the anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement. If palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Because of the central role of lymph nodes in the immune system, they are prioritized over the heart, liver, and abdomen, even though these would be assessed.
Question 5 of 5
A patients exposure to which of the following microorganisms is most likely to trigger a cellular response?
Correct Answer: A
Rationale: Viral, rather than bacterial antigens, induce a cellular response.