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 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 2 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 3 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 4 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.
Question 5 of 5
A patient was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response?
Correct Answer: B
Rationale: In the proliferation stage, T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. This does not occur in the response, recognition, or effector stages.