PCC Exam III Questions & Answers

PCC Exam III Questions & Answers The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population ANS: B The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control. REF: Page 219 An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a. Primary immunodeficiency b. Secondary immunodeficiency c. Cancer d. Autoimmunity ANS: A Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity. REF: Page 221 Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:15 Full screen Brainpower Read More The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition? a. His immune system is functioning properly. b. He is properly vaccinated. c. He has an infection. d. The suppressor T-cells in his body are activated. ANS: A Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area from invasion of microorganisms and pathogens with inflammation. Routine vaccinations have no bearing on the body's response to intentional tissue impairment. The redness and swelling at the incision site in the first 12 to 24 hours is part of optimal immune functioning. A patient with erythema and edema that persist or worsen should be evaluated for infection. Suppressor T-cells help to control the immune response in the body. REF: Page 225 While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? a. "My body will treat the new kidney like my original kidney." b. "I will have to make sure that I avoid being around people." c. "The medications that I take will help prevent my body from attacking my new kidney." d. "My body will only have a problem with my new kidney if the donor is not directly related to me." ANS: C Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don't have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient. REF: Page 222 The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a. Suppressed immune response b. Hyperimmune response c. Allergic reaction d. Anaphylactic reaction ANS: D The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While the patient is experiencing a hyperimmune response, the signs and symptoms allow for a more specific response. While the patient is experiencing an allergic reaction, the signs and symptoms presented in the scenario allow for a more specific response. REF: Page 221 - Page 225 The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient? a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain ANS: C Medications for RA are intended to control the inflammation that results from the body's hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation. REF: Page 223 - Page 224 The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC) ANS: B, D, F Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people at various ages from infants to older adults. Vaccination does not guarantee that the recipient won't get the disease, but it decreases the potential to contract the illness. No medication is risk free. REF: Page 224 The nurse is caring for a client who is hospitalized on a medical unit for a systemic infection. The client asks the nurse what defenses the body has against infection. The nurse responds that which physiological barrier helps defend the body against microorganisms? Select all that apply. A) Moisturizing the skin B) Adequate urinary output C) Intact skin D) Occasional smoking E) A surgical incision Answer: B, C Explanation: Voiding a sufficient quantity of urine is a form of barrier protection that helps the body to defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Intact skin is also a physiological barrier that helps defend the body against microorganisms. Occasional smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. Moisturizing the skin and a surgical incision can both allow microorganisms to enter the body. A client, who has been given a yellow fever vaccine before traveling to the Amazon Basin, asks the nurse to explain how the elements of the immune system will now provide protection. Which is the appropriate response by the nurse? Select all that apply. A) "Human macrophages engulf the weakened vaccine virus as if it is dangerous and antigens stimulate the immune system to attack it." B) "In the lymph nodes, part of the lymphoid system, the macrophages present yellow fever antigens to T cells and B cells." C) "A response from yellow fever-specific T cells is activated. B cells secrete yellow fever antibodies." D) "The body's immune system eats away at the protective sheath (myelin) that covers the nerves." E) "The initial weak infection is eliminated and the client is left with a supply of memory T and B cells for future protection against yellow fever." Answer: A, B, C, E Explanation: Macrophages ingest antigens and signal helper T cells that antigens are present. Lymph nodes filter foreign products or antigens from the lymph system and house and support proliferation of lymphocytes and macrophages. Antibodies directly attack and destroy antigens either before or after antigens invade body cells. The immune system damaging the myelin is an autoimmune response in MS. Memory B cells and T cells remember how to identify the antigen and will reactivate at a future time if the same type of antigen is present. A nurse is volunteering in a health screening booth at the state fair. The nurse has assessed several clients and determines that which client demonstrates the decline in responsiveness of the immune system of an older adult? A) An 88-year-old client with pneumonia who has a temperature of 99.5°F B) A 70-year-old client who has swelling and redness around an abdominal incision from an open appendectomy C) A 58-year-old client who complains of redness and itching after developing a rash from contact with poison ivy D) A 56-year-old client who has 8 mm induration at the site of a PPD skin test 72 hours earlier Answer: A Explanation: The client who has only a slight elevation in temperature in response to pneumonia is an example of a decline in the expected immune response. The other clients are demonstrating an expected immune response as evidenced by redness, swelling, and induration. A client who has been diagnosed with untreated HIV comes in complaining of fatigue and weight loss. What are some important elements of the physical exam for evaluating the client's AIDS status? Select all that apply. A) Assess the general appearance. B) Assess skin color, temperature, and moisture. C) Assess hair loss. D) Inspect the skin for evidence of rashes or lesions. E) Inspect the mouth for lesions. Answer: A, B, D, E Explanation: Assess height, weight, and body type for apparent weight loss or wasting. Pallor may indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth lesions, which may have a "cottage cheese" appearance, may indicate candida. The nurse is caring for a client being seen at an urgent care clinic because of an infected arm. The client tells the nurse he was bitten by a raccoon on a recent camping trip. The nurse expects treatment for this client to include which of the following? A) An injection of immunoglobulin B) A tetanus toxoid injection C) Mother's breast milk with antibodies in it D) An immunization for rabies Answer: D Explanation: Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but would not be used in the case of an animal bite. Mother's breast milk is another example of passive immunity, but would not be used in the case of an animal bite. The nurse is caring for a client in an allergy clinic. The nurse believes the client is having a reaction to a specific antigen. Which lab test would the nurse assess in order to determine the possibility of a hypersensitivity reaction? A) Indirect Coombs' showing no agglutination B) Patch test with a 1-inch area of erythema C) 2% eosinophils in the WBC count D) Rh antigen with negative results Answer: B Explanation: A patch test assesses a 1-inch area impregnated with the allergen, which is applied for 48 hours. Absence of a response indicates a negative result. Positive responses are graded from mild (erythema in the exposed area) to severe (papules, vesicles, or ulcerations). Direct Coombs' test detects antibodies in the client's RBC that damage and destroy the cells. This is used following a suspected transfusion reaction to detect antibodies coating the transfused RBCs. This is also part of the crossmatch of a blood type and crossmatch. Indirect Coombs' test detects the presence of circulating antibodies against RBCs. The eosinophil count is 1% to 4%, which is within normal range. The nurse is teaching a group of young parents at the local elementary school health fair about immunity and the importance of vaccination. The nurse is giving the group an example of how active immunity is acquired. Which scenario would provide a client with active immunity? A) Receiving a rabies shot after being bitten by a rabid dog B) Having measles C) Receiving an injection of gamma globulin D) Becoming ill with tetanus and receiving tetanus toxoid Answer: B Explanation: When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity.