Chapter 34: Immunologic Disorders Nursing School Test Banks

Chapter 34: Immunologic Disorders
Linton: Introduction to Medical-Surgical Nursing, 6th Edition

MULTIPLE CHOICE

1. What is responsible for initiating the inflammatory response in addition to immunoglobulin E (IgE)?
a. Eosinophils
b. Lymphocytes
c. Basophils
d. Neutrophils
ANS: C
Basophils initiate a massive inflammatory response with histamine that quickly brings other white blood cells (WBCs) to the site of an infection.

DIF: Cognitive Level: Knowledge REF: p. 643 OBJ: 1
TOP: Components of the Immune System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. Where are histamine-releasing mast cells located?
a. Circulating in the blood
b. Circulating in the lymph
c. Attached to organ tissue
d. Embedded in the bone marrow
ANS: C
Mast cells are located in organ tissue when they release their histamine. The organ to which they are attached is the host of the inflammatory response. If the organ is the lung, the response may be asthma; if the organ is the colon, the response may be diarrhea.

DIF: Cognitive Level: Knowledge REF: p. 643 OBJ: 1
TOP: Mast Cells KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. What is true concerning passive-acquired immunity?
a. Antibodies are acquired from outside the host and instilled in the host.
b. Antibodies are manufactured in response to a disease in the host.
c. Antibodies are innately acquired because of being born a human being.
d. Antibodies are cell mediated inside the host.
ANS: A
Gamma globulin injections provide passive-acquired immunity. The antibodies that are injected have been produced by another host, collected, fused in the mixture, and injected into a separate host. This gives the host a passive-acquired immunity that lasts for only 2 to 3 months.

DIF: Cognitive Level: Knowledge REF: p. 646 OBJ: 1
TOP: Functions of the Immune System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. A nurse is alerted by the laboratory regarding a patients complete blood count that shows a large shift to the left. What should the nurse assess this to mean about cell level count?
a. Neutrophils have dropped by 10%.
b. Basophils have increased by 25%.
c. Neutrophils have increased by 25%.
d. Neutrophils have increased by 60%.
ANS: D
A shift to the left indicates a sharp rise in the neutrophils to approximately 60%. The outpouring of these cells from the marrow indicates a serious and perhaps overpowering infection. Many of the cells are young and will not be able to keep up their work of immunity for as long as more mature cells would maintain immunity.

DIF: Cognitive Level: Comprehension REF: p. 651 OBJ: 3
TOP: Nursing Diagnosis KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. Which symptom should a nurse recognize as being pertinent to a possible diagnosis of systemic lupus erythematosus (SLE)?
a. Butterfly rash of the face
b. Protruding abdomen
c. Thinning hair
d. Bloody diarrhea
ANS: A
The classic butterfly rash of the face is one of the most recognizable signs. Because the symptoms come and go, SLE is extremely hard to diagnose quickly.

DIF: Cognitive Level: Comprehension REF: p. 658 OBJ: 5
TOP: Systemic Lupus Erythematosus KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. A hospitalized patient has been prescribed dexamethasone (Decadron) for an allergic reaction. Which teaching instruction should the patient be given with discharge relative to this drug?
a. Report blurry vision.
b. Take the medication on an empty stomach.
c. Do not operate heavy machinery.
d. Take this medication with meals.
ANS: D
Steroid therapy can cause gastrointestinal discomfort when taken on an empty stomach.

DIF: Cognitive Level: Application REF: p. 660 OBJ: 4
TOP: Drug Therapy Used to Treat Immunologic Disorders
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A patient taking dexamethasone (Decadron) reports insomnia. What is the best information to provide this patient regarding administration of this medication?
a. Take with milk.
b. Take at breakfast.
c. Dissolve in fruit juice.
d. Take at bedtime.
ANS: B
Patients taking steroids should take them early in the day to avoid sleep disturbances.

DIF: Cognitive Level: Knowledge REF: p. 660 OBJ: 4
TOP: Insomnia with Steroids KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

8. What should a nurse include when developing a plan of care for a patient with human immunodeficiency virus (HIV)?
a. Careful aseptic technique to prevent infection
b. Instruction to limit fluids to prevent congestive heart failure
c. Oral alcohol rinses to control mouth infections
d. Selections of high-fat foods in the daily diet
ANS: A
A major complication of HIV is opportunistic infections.

DIF: Cognitive Level: Application REF: p. 652 OBJ: 6
TOP: Prevention of Infection in Patients with Human Immunodeficiency Virus (HIV)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

9. An 11-year-old girl is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which parental statement helps the nurse evaluate that teaching is successful?
a. Our daughter can still be involved in gymnastics.
b. When our daughters hemoglobin falls below 3.5, shell need blood.
c. Our daughter will need genetic counseling before she marries.
d. Our daughter should avoid drugs containing sulfonamides.
ANS: D
Drugs known to induce ITP include sulfonamides.

DIF: Cognitive Level: Application REF: p. 657 OBJ: 6
TOP: Idiopathic Thrombocytopenic Purpura Care Plan
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

10. A nurse is preparing a patient for a liver and spleen scan. Which intervention is most important to implement before the procedure?
a. Prepare the biopsy site with a clean field.
b. Check for any allergies to contrast media.
c. Explain the procedure to the patients family.
d. Have the patient eat a complete regular diet.
ANS: B
Allergies should always be checked before any diagnostic test.

DIF: Cognitive Level: Application REF: p. 650 OBJ: 3
TOP: Preparation for Diagnostic Tests KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

11. After a bone marrow transplant, a patient is placed on a protocol of chemotherapy and radiation and the nursing diagnosis of risk for injury is added. Which nursing assessment should cause the nurse concern?
a. Increased urine output
b. Decreasing bilirubin levels
c. Increasing blood pressure
d. Increasing abdominal girth
ANS: D
High doses of chemotherapy and radiation can damage the liver, which would lead to increasing abdominal girth with ascites and increasing bilirubin levels.

DIF: Cognitive Level: Application REF: p. 651-653 OBJ: 6
TOP: Bone Marrow Transplantation Risk
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. A patient diagnosed with leukemia has had a bone marrow transplant and has completed chemotherapy. What is the greatest risk for this patient while healthy bone marrow is growing back?
a. Infection and bleeding
b. Hypertension and headache
c. Oliguria and urinary retention
d. Dyspnea and wheezing
ANS: A
Patients are at greater risk for infection and bleeding while their healthy bone marrow is growing back.

DIF: Cognitive Level: Comprehension REF: p. 655 OBJ: 4
TOP: Bone Marrow Complications KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

13. What is most appropriate for a nurse to include when preparing discharge plans for a patient with SLE?
a. Need to consume 2 L of fluid daily
b. Close monitoring of daily blood glucose level
c. Use of daily sunscreens with a sun protection factor (SPF) higher than 15
d. Careful concern for certain food allergies
ANS: C
Patients with SLE are photosensitive to sunlight.

DIF: Cognitive Level: Application REF: p. 658 OBJ: 6
TOP: Systemic Lupus Erythematosus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. A nurse is caring for a patient with thrombotic thrombocytopenic purpura who is having plasmapheresis every day. Which assessment alerts the nurse of a complication?
a. Hypotension
b. Seizure activity
c. Diarrhea
d. Intense headache
ANS: A
During the period of treatment by plasmapheresis, the patient can become hemodynamically unstable and have a reduced cardiac output with the attendant hypotension. This is a serious complication and can lead to renal failure.

DIF: Cognitive Level: Application REF: p. 657-658 OBJ: 2
TOP: Thrombotic Thrombocytopenic Purpura
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. A nurse assesses a neutrophil count of 900/mm3 in a patient with acute leukemia. What should the nurse anticipate initiating?
a. A high-protein diet
b. Increased doses of steroids
c. Compromised host precautions
d. Injections of blood-building medication
ANS: C
Patients with neutrophil counts of approximately 1000 cells/mm3 are placed on compromised host precautions.

DIF: Cognitive Level: Application REF: p. 655-656 OBJ: 5
TOP: Compromised Host Precautions KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. A nurse is caring for a patient in the last stages of leukemia and is aware that the patient is at risk from the bacteria of his own body. Which is an example of internal bacteria?
a. Beta-hemolytic streptococci
b. Streptococcus pneumoniae
c. Streptococcus viridans
d. Pseudomonas aeruginosa
ANS: D
Internal bacteria such as P. aeruginosa and Escherichia coli are capable of attacking the compromised immune system from inside the body.

DIF: Cognitive Level: Comprehension REF: p. 656 OBJ: 5
TOP: Risk for Infection in Leukemia KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The nursing staff of an oncology unit cautions visitors to be free of infections before visiting patients. What can chemotherapy and decreased bone marrow production cause in these patients?
a. Hemorrhage
b. Neutropenia
c. Edema
d. Hypovolemia
ANS: B
Neutropenia occurs when the total number of neutrophils is abnormally low, placing the patient at increased risk for infection.

DIF: Cognitive Level: Comprehension REF: p. 655 OBJ: 4
TOP: Neutropenia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A 24-year-old woman is admitted to the hospital for a complete medical examination. Her current complaints are indicative of SLE. Which symptom would indicate this diagnosis?
a. Recent weight gain of 10 lb
b. Difficulty breathing in the morning
c. Frequent episodes of diarrhea
d. Musculoskeletal pain in the hands
ANS: D
Musculoskeletal symptoms are experienced by 95% of patients with SLE at some time during the course of their disease.

DIF: Cognitive Level: Comprehension REF: p. 658 OBJ: 2
TOP: Systemic Lupus Erythematosus KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. What is the primary function in the immune process of the spleen?
a. Filter microorganisms from the blood.
b. Store lymphocytes used to fight infections.
c. Produce additional RBCs (red blood cells).
d. Stimulate WBC production.
ANS: A
The spleen filters microorganisms from the blood.

DIF: Cognitive Level: Knowledge REF: p. 644 OBJ: 1
TOP: Functions of the Spleen KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. Which laboratory result for a patient with acute leukemia should alert the nurse to the fact that the drug protocols are not effective?
a. Decreased prothrombin time
b. Platelet count lower than 50,000/mm3
c. Negative Western blot result
d. Neutrophils 50% to 62%
ANS: B
A low platelet count predisposes a patient to bleeding. A count less than 50,000/mm3 is cause for concern.

DIF: Cognitive Level: Comprehension REF: p. 654-657 OBJ: 3
TOP: Platelet Count KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. Which observation by a nurse indicates a patients acceptance of the diagnosis of acute leukemia?
a. Plans a 14-day cruise in 2 weeks
b. States that he will be fine in a few months
c. Asks for educational material about acute leukemia
d. Rests after a chemotherapy session
ANS: C
Asking for educational material indicates beginning acceptance.

DIF: Cognitive Level: Application REF: p. 654-657 OBJ: 5
TOP: Nursing Care KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

22. A skin test shows redness and swelling a few days after injection. What type of hypersensitivity reaction should the nurse document?
a. I
b. II
c. III
d. IV
ANS: D
A type IV reaction is set in motion when immune cells migrate to the site of an antigen exposure and set up a local inflammatory response.

DIF: Cognitive Level: Application REF: p. 657 OBJ: 5
TOP: Hypersensitivity Reactions KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The nursing staff decides on a nursing diagnosis of Imbalanced nutrition: less than body requirements for a patient with leukemia. Which goal is most realistic for this patient?
a. To gain 5 lb, eat foods high in calories at each meal.
b. To avoid nausea, eat slowly, and eat small meals.
c. To consume all food at every meal, offer three large meals.
d. To maintain a stable weight, eat small meals, and avoid vomiting.
ANS: D
A goal for Imbalanced nutrition: less than body requirements would be maintaining a stable weight.

DIF: Cognitive Level: Comprehension REF: p. 656 OBJ: 6
TOP: Nursing Care of Leukemia Patients
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

24. A patient has undergone bone marrow transplant. Which injection should the nurse anticipate this patient will receive to help stabilize the immune response and prevent rejection?
a. Dexamethasone (Decadron)
b. Filgrastim (Neupogen)
c. Zidovudine (Retrovir)
d. Nevirapine (Viramune)
ANS: A
Steroids (e.g., dexamethasone [Decadron]) are drugs used in the treatment of patients with transplanted organs to prevent rejection.

DIF: Cognitive Level: Knowledge REF: p. 660 OBJ: 5
TOP: Drugs to Prevent Rejection of Transplanted Organs
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

25. What type of bone marrow transplant uses the patients own bone marrow?
a. Allergenic
b. Allogeneic
c. Peripheral blood stem cell
d. Autologous
ANS: D
An autologous bone marrow transplant uses the patients own bone marrow.

DIF: Cognitive Level: Knowledge REF: p. 653 OBJ: 3
TOP: Bone Marrow Transplantation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

26. Which human immunity is an example of innate immunity?
a. Hoof-and-mouth disease
b. Measles
c. Rabies
d. Mange
ANS: A
Humans, by nature of their innate properties at birth, have an innate immunity to hoof-and-mouth disease. Cows also have an innate immunity to measles.

DIF: Cognitive Level: Comprehension REF: p. 644 OBJ: 1
TOP: Innate Immunity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. Which nursing action should be implemented when performing skin testing?
a. Select an 18-gauge needle.
b. Inject 1 mL intradermally.
c. Check the site in 2 to 3 days for swelling.
d. Wrap the site with a pressure dressing.
ANS: C
A cell-mediated response will show swelling in 2 to 3 days, indicating antibodies working at the site of the exposure to an antigen.

DIF: Cognitive Level: Application REF: p. 650 OBJ: 3
TOP: Skin Testing Procedure KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

28. What are the four distinct stages of the inflammatory process?
a. Dolor
b. Rubor
c. Tumor
d. Calor
e. Rumor
ANS: A, B, C, D
The four processes are rubor (red), tumor (swelling), calor (heat), and dolor (pain).

DIF: Cognitive Level: Knowledge REF: p. 645 OBJ: 1
TOP: Stages of Inflammatory Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. A nurse explains that in autoimmune diseases, the body identifies its own proteins as foreign matter and sets out to destroy itself. Which are examples of autoimmune diseases? (Select all that apply.)
a. SLE
b. Type 1 diabetes mellitus (DM)
c. Rheumatoid arthritis (RA)
d. Osteoarthritis
e. Pancreatitis
ANS: A, B, C
The autoimmune diseases are SLE, type 1 DM, and RA.

DIF: Cognitive Level: Knowledge REF: p. 646 OBJ: 5
TOP: Autoimmune Diseases KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

30. A nurse explains that early in life, lymphocytes migrate from the marrow of the bones to the _____, in which they mature into T cells.

ANS:
thymus
The lymphocytes migrate and mature to T cells in the thymus.

DIF: Cognitive Level: Comprehension REF: p. 644 OBJ: 1
TOP: Thymus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

31. Cells in the bone marrow that are capable of developing into RBCs, WBCs, or platelets are the _____ cells.

ANS:
stem
Adult stem (progenitor) cells can evolve into WBCs, RBCs, or platelets. Stem cells from an embryo can mature into any specialized cell. Adult stem cells are limited to cells of their origin.

DIF: Cognitive Level: Comprehension REF: p. 642 OBJ: 1
TOP: Adult Stem Cells KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

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