ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 16 Questions
Question 1 of 5
The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with which of the following types of immunity?
Correct Answer: C
Rationale: Colostrum provides passive immunity through antibodies from the mother; these antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Innate immunity is present at birth and occurs without exposure to an antigen. Active immunity requires that the infant manufacture antibodies after exposure to an antigen. Cell-mediated immunity is acquired through T-lymphocytes and is a form of active immunity.
Question 2 of 5
After being stung by a wasp, a patient is brought to the clinic by a coworker. Upon arrival the patient is anxious and having difficulty breathing. Which of the following actions is priority for the nurse to implement?
Correct Answer: B
Rationale: The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance.
Question 3 of 5
The nurse is completing an assessment and health history with a patient. Which of the following statements made by the patient should alert the nurse to a possible immunodeficiency disorder?
Correct Answer: C
Rationale: Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily Aspirin use does not impact immune function. A chest x-ray does not have enough radiation to suppress immune function.
Question 4 of 5
Immediately after the nurse administers an intradermal injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. Which of the following actions is priority for the nurse to implement?
Correct Answer: C
Rationale: Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local anti-inflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action.
Question 5 of 5
The nurse is caring for a patient who has experienced Goodpasture's syndrome. Which of the following adverse effects should the nurse be aware of?
Correct Answer: D
Rationale: Goodpasture's syndrome is a rare disorder involving the lungs and the kidneys. An antibody-mediated autoimmune reaction occurs involving the glomerular and alveolar basement membranes. The circulating antibodies combine with tissue antigen to activate the complement system which causes deposits of IgG to form along the basement membranes of the lungs or the kidneys. This reaction may result in pulmonary hemorrhage and glomerulonephritis.