ATI LPN
Immune System Questions Questions
Question 1 of 5
What is the primary characteristic of an autoimmune disease?
Correct Answer: B
Rationale: The primary characteristic of an autoimmune disease is that the immune system attacks the body's own healthy tissues. This is because in autoimmune diseases, the immune system mistakenly identifies normal cells and tissues as foreign invaders and mounts an immune response against them. This leads to inflammation, tissue damage, and various symptoms of the autoimmune disease. Incorrect choices: A: The immune system failing to recognize foreign pathogens is not the primary characteristic of an autoimmune disease. Autoimmune diseases involve the immune system mistakenly attacking the body's own tissues. C: While an overactive immune system producing excessive antibodies can be a feature of some autoimmune diseases, it is not the primary characteristic. The key feature is the immune system attacking healthy tissues. D: An immune system that is suppressed and cannot fight infections effectively is not characteristic of autoimmune diseases. Autoimmune diseases involve an immune system that is active but targeting the wrong cells.
Question 2 of 5
Systemic lupus erythematosus is:
Correct Answer: D
Rationale: The correct answer is D: An autoimmune condition. Systemic lupus erythematosus is an autoimmune disease where the immune system mistakenly attacks healthy tissues in the body. This condition is not infectious (choice A), not harmless (choice B), and not always associated with HIV (choice C). Lupus is characterized by inflammation and damage to various organs, joints, and skin. It is important to differentiate autoimmune diseases like lupus from infectious diseases and understand their underlying mechanisms for proper diagnosis and treatment.
Question 3 of 5
A school-age child with hemophilia falls on the playground and goes to the school nurse with superficial bleeding above the elbow. What is the most appropriate action by the nurse?
Correct Answer: B
Rationale: The correct answer is B: Apply pressure for at least 15 minutes. This is the most appropriate action as it helps control bleeding by promoting clot formation. Applying pressure directly on the wound site can help stop the bleeding effectively. Warm, moist compresses (choice A) may not provide enough direct pressure to stop bleeding. Keeping the affected extremity in a dependent position (choice C) can increase bleeding due to gravity. Beginning passive range of motion (choice D) could exacerbate bleeding if a clot has not formed yet. Therefore, applying pressure for at least 15 minutes is the best initial action to control bleeding in this situation.
Question 4 of 5
When completing the child’s admission assessment, which of the following components of the abdominal assessment should the nurse avoid?
Correct Answer: B
Rationale: The correct answer is B: Palpation. During a child's admission assessment, the nurse should avoid palpation of the abdomen because it can potentially cause discomfort or pain to the child, especially if there is an underlying abdominal issue. Instead, the nurse should prioritize other components such as inspection, auscultation, and percussion. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation helps in listening for bowel sounds, which can provide valuable information about gastrointestinal function. Percussion can assist in identifying areas of tenderness or abnormal fluid accumulation. Palpation should be performed cautiously and only if necessary, after obtaining consent and ensuring the child is comfortable.
Question 5 of 5
The nurse is administering packed red blood cells to a child with sickle cell disease (SCD). The nurse is monitoring for a transfusion reaction and knows it is most likely to occur during which time frame?
Correct Answer: B
Rationale: The correct answer is B: Within the first 20 minutes of administration of the transfusion. During the initial stage of transfusion, reactions are most likely to occur due to rapid infusion of blood. This is when the nurse should closely monitor the child for signs of transfusion reactions such as fever, chills, rash, or shortness of breath. Reactions can be severe and life-threatening, so early detection is crucial. Choices A, C, and D are incorrect because reactions are most likely to occur at the beginning of the transfusion due to immediate immune responses, rather than hours later, at the end of the transfusion, or not at all.