Chapter 59
1. A patient is admitted with a large inflamed leg wound. The nurse realizes that the white
blood cell type responsible for initiating the inflammatory response is the:
1. Basophil.
2. Neutrophil.
3. Eosinophil.
4. Monocyte.
Answer: Basophil.
Rationale:
Basophils mature into mast cells that are filled with granules of histamine that, in response to
an injury, release large quantities of histamine that stimulate the inflammatory response.
Neutrophils consume cellular debris and bacterial and viral particles. Eosinophils increase in
the presence of parasites and allergies. They increase the inflammatory response, rather than
initiate it. Monocytes arrive at the site of an injury hours or days after the neutrophils and
continue to consume large amounts of cellular debris.
2. A patient tells the nurse that she washes her hands many times throughout the day because
she wants to kill all of the germs before she provides care to her small children. Which of the
following is the nurse’s best response to this patient?
1. “Bacteria are always present on the skin, and too much hand washing could lead to skin
breakdown.”
2. “That’s a good thing, because hand washing will kill all bacteria.”
3. “Make sure you use an antibiotic ointment on areas of skin breakdown.”
4. “Bacteria can’t grow on the skin, so the hand washing is not needed.”
Answer: “Bacteria are always present on the skin, and too much hand washing could lead to
skin breakdown.”
3. A patient asks the nurse how the body identifies bacteria and then proceeds to kill them.
The nurse should instruct the patient about:
1. The presence and shape of toll receptors in the cells.
2. The importance of an alkaline environment in the stomach.
3. The role of skin in killing bacteria.
4. The need to retain the tonsils and adenoids.
Answer: The presence and shape of toll receptors in the cells.
Rationale:
The toll receptors are present at the cellular level and initiate immune responses when pieces
of bacterial cell walls attach to them. Humans are born with these toll receptors, and they
provide innate protection for the body. The ideal stomach pH environment is acidic, not
alkaline. The skin serves as a barrier to the entry of bacteria into the body and does not kill
bacteria. Tonsils and adenoids are important in filtering bacteria and viruses from the upper
airways and the mouth.
4. A patient is admitted with an autoimmune disorder. The nurse realizes this disorder occurs
when the body:
1. Does not recognize self receptors.
2. Does not recognize non-self receptors.
3. Does not have enough white blood cells to combat infections.
4. Has an overproduction of histamine.
Answer: Does not recognize self receptors.
Rationale:
When the body reacts to self receptors, autoimmune disease may result. The normal body
response is to recognize non-self receptors and eliminate them from the body. White blood
cells, or histamine release, is not an issue with the basic underlying cause for the
development of an autoimmune disorder.
5. A patient tells the nurse that he is 65 years old and has not had a cold or any other type of
infection for at least 30 years. The nurse realizes this patient most likely has:
1. Intact functioning MHC receptors.
2. An overabundance of white blood cells.
3. An enlarged spleen.
4. Engorged lymph nodes.
Answer: Intact functioning MHC receptors.
Rationale:
Major histocompatiblity complex or MHC receptors on cells are one type of marker used by
the immune system to determine if a cell belongs to the organism or not. Because this patient
claims he has not had a cold or other inflammatory response for at least 30 years, the nurse
can surmise that this patient’s MHC receptors are well functioning. There is not enough
information to know if the patient has an elevated white blood cell count. An enlarged spleen
and engorged lymph nodes are signs of an infection or inflammatory process somewhere in
the body.
6. The nurse is instructing a female patient who is 6 weeks pregnant. Which of the following
should the nurse include in this instruction to ensure the development of an intact immune
system for the baby once it is born?
1. Eliminate exposure to known carcinogens so that the baby’s immune tolerance will
develop normally.
2. Limit alcohol consumption to two drinks or fewer per day.
3. Reduce smoking.
4. Engage in light physical activity during the pregnancy.
Answer: Eliminate exposure to known carcinogens so that the baby’s immune tolerance will
develop normally.
Rationale:
Immune tolerance begins during embryonic development of the immune system. For the
immune system to develop normally, the patient should be instructed to eliminate exposure to
known carcinogens. The patient should be instructed to eliminate alcohol and smoking. The
patient may or may not need to limit exercise or engage in light physical activity only.
7. A patient tells the nurse that he’s happy that his wife did not “catch” the same cold from
which he has recently recovered. The nurse realizes that which of the following most likely
occurred in his wife?
1. T-helper 2 memory of a previous exposure to the same virus that caused the patient’s
illness
2. T-helper 1 stimulation to kill unidentified cells
3. Proliferation of CD 8 cells
4. Release of cytokines
Answer: T-helper 2 memory of a previous exposure to the same virus that caused the patient’s
illness
Rationale:
T-helper 2 cells stimulate B cells to make antibodies to specific antigens. These cells then
have a “memory” of exposure that will lead to a quick response if another exposure occurs. In
the case of the patient with his wife, the wife must have had a previous exposure to the same
virus that caused the patient’s cold and because of the “memory,” the body immediately
responded by eliminating the cold virus. T-helper 1 cells help upregulate immune activity and
produce chemicals to destroy mutant cells. CD 8 cells slow or stop the immune response.
Cytokines are chemical messages produced by cells to either increase the flow of white blood
cells to a body area or coat an antigen to encourage phagocytosis.
8. The nurse is caring for patient who has a lung infection, resulting in elevated
____________ levels in this patient.
1. Immunoglobulin A
2. Immunoglobulin M
3. Immunoglobulin E
4. Immunoglobulin D
Answer: Immunoglobulin A
Rationale:
Immunoglobulins are made in response to a primary or initial exposure to an antigen.
Immunoglobulin A is most commonly found in secretions and has the major function to
protect the eyes, mouth, nose, gastrointestinal tract, and lungs from disease caused by viruses
and bacteria. For the patient with a lung infection, this immunoglobulin level will most likely
be the highest. Immunoglobulin M is the first antibody produced in the primary immune
response and is first produced during embryonic development. Immunoglobulin E is the
primary antibody in the allergic response. Immunoglobulin D is the cell that is least
understood and is present in small quantities in the blood.
9. While studying the antibody−antigen response, the nurse realizes that an antibody can
receive different types of antigens to protect the body from illness and disease. The body’s
ability to conform to the different antigens is considered:
1. Humoral immunity.
2. Cell-mediated immunity.
3. Immune tolerance.
4. Natural immunity.
Answer: Humoral immunity.
Rationale:
Humoral immunity is a mechanism where antibodies bind to antigens to immobilize or
destroy them. Cell-mediated immunity is where the T white blood cells are stimulated to
decrease the immune response. Immune tolerance is the immune system’s ability to tolerate
self antigens while retaining the ability to respond to non-self antigens. Natural immunity is
the term used to describe the cells, organs, and secretions of the body that provide protection
from foreign particles or other non-self invaders.
10. A patient is diagnosed with a viral infection. The nurse realizes that which of the
following chemicals produced by the immune system will participate in the patient’s body to
fight this infection?
1. Interferon
2. Tumor necrosis factor
3. Tissue factor
4. Interleukin
Answer: Interferon
Rationale:
Interferons are proteins made and released by T cells when the invading organism is a virus.
Interferons protect other cells from viral attack, inhibit the production of the virus within
infected cells, prevent the spread of the virus to other cells, and enhance the activity of
macrophages to kill the virus. Tumor necrosis factor is a small peptide that is instrumental in
the initiation of the inflammatory response. Tissue factor stimulates platelets to begin clot
formation and stop blood loss from injured blood vessels. Interleukin enable the cells of the
immune system to communicate and coordinate the immune response.
11. A patient is admitted with liver cirrhosis. The nurse realizes that this patient’s immunity
might be affected because:
1. Complement is made in the liver and has a role in inflammatory and immune responses.
2. White blood cells are stored in the liver.
3. Red blood cells are made in the liver.
4. Interferon will not function in this patient.
Answer: Complement is made in the liver and has a role in inflammatory and immune
responses.
Rationale:
Complement is a group of small proteins made in the liver and present in the blood and is
important in the inflammatory and immune response. White blood cells are not stored in the
liver. Red blood cells are not made in the liver. There is no evidence to suggest that interferon
will not function in this patient.
12. While reviewing a patient’s laboratory values, the nurse notes that the Complement 3b
level is below normal limits. This finding would result in which of the following patient
responses?
1. The body is not going to recognize all offending cells or antigens for elimination.
2. The body will not be able to call phagocytic cells to areas of infection.
3. The body will not be able to recognize the need for platelets to stop blood lost from vessel
injury.
4. The body will not be able to inhibit tumor development caused by chronic inflammation.
Answer: The body is not going to recognize all offending cells or antigens for elimination.
Rationale:
The function of Complement 3b is to coat or attach to antigens or offending cells to make the
cells/antigens attractive to phagocytes in order to consume the cell or antigen. Levels below
normal limits mean the body might not be able to recognize all offending cells or antigens for
elimination. Complements 3b and 5a are responsible for calling phagocytic cells to areas of
infection. Tissue factor is the chemical that stimulates platelets to clot and stop the flow of
blood from injured vessels. Tumor necrosis factor is the chemical that inhibits tumor
development caused by chronic inflammation.
13. The parent of a young patient asks the nurse why her child should receive the measlesmumps-rubella vaccination. Which of the following is the nurse’s best response to this
mother?
1. “Receiving the vaccination will cause your child to develop active acquired immunity,
which will protect against the development of these illnesses.”
2. “The child can always receive the vaccination if he wants it later.”
3. “Your child will develop immunity to these illnesses even without the vaccination, but at a
slower rate.”
4. “I know that the Centers for Disease Control expects everyone to have this vaccination, but
you can always refuse.”
Answer: “Receiving the vaccination will cause your child to develop active acquired
immunity, which will protect against the development of these illnesses.”
Rationale:
Acquired immunity is that which occurs after birth and happens after either contracting the
disease or through a vaccination. The nurse should respond that the vaccination will cause the
development of active immunity in the child to prevent the development of the illnesses. The
measles-mumps-rubella vaccination is often provided to the school-age child; suggesting the
child may receive the vaccination at a later time does not answer the parent’s question. The
child may or may not develop immunity to these illnesses. The Centers for Disease Control
does support that every person receive this immunization. The nurse should not encourage the
parent to refuse this vaccination for her child.
14. A 50-year-old patient asks the nurse if the smallpox vaccination she received as a child
will prevent her from developing the disease if exposed at this time of her life. Which of the
following is the nurse’s best response to this patient?
1. “I would discuss revaccination for smallpox with your health care provider because, as we
age, the antibodies age as well, and it could affect the body’s immune response to the
disease.”
2. “Of course you have protection against the disease.”
3. “Smallpox has been eradicated, so there’s nothing to worry about.”
4. “There’s little chance that you will be exposed to smallpox now.”
Answer: “I would discuss revaccination for smallpox with your health care provider because,
as we age, the antibodies age as well, and it could affect the body’s immune response to the
disease.”
Rationale:
The smallpox vaccine that many people received up to 50 years ago is now providing only a
percentage of protection against smallpox. As an individual ages, the cells that make the
antibodies age as well, and this can affect the immune response to the disease. The nurse
should counsel the patient to discuss the possible need to be revaccinated for smallpox. The
nurse should not tell the patient that she definitely has protection against the disease. The
nurse should not minimize the patient’s fears by saying that smallpox has been eradicated or
by saying that there’s little chance that she will be exposed to smallpox now.
15. A parent tells the nurse that he has not had his child immunized for any illnesses and the
only problem the child has had is ear infections. Which of the following does this suggest to
the nurse?
1. The child would have benefited from receiving the pneumococcal vaccine.
2. The child would have benefited from receiving the annual flu vaccination.
3. The child has outstanding natural immunity.
4. The child has escaped unnecessary pain from the immunizations.
Answer: The child would have benefited from receiving the pneumococcal vaccine.
Rationale:
The pneumococcal vaccine is recommended by the Centers for Disease Control for children
under age 2 and those in day care. Pneumococcal infections can lead to illnesses with the
sinuses and ears such as otitis media. The mother states that the only illnesses the child has
experienced are ear infections. The pneumococcal vaccine might have prevented these ear
infections. There is no evidence to suggest that the annual flu vaccination would prevent ear
infections. There is no evidence to suggest that the child has outstanding natural immunity.
The temporary discomfort from receiving the vaccinations is outweighed by the acquired
active immunity that results from receiving the vaccinations.
16. A patient is demonstrating signs of a delayed immunological response to a virus. Which
of the following is responsible for beginning this response?
1. Intact functioning T cells
2. Intact functioning B cells
3. Complement
4. Functioning human leukocyte antigens
Answer: Intact functioning T cells
Rationale:
T lymphocytes are the regulatory cells of the immune system whose function is to start and
stop the immune process. When these cells are not functioning correctly, they will not
chemically bind to an offending organism or cell and present the cell or organism to the B
cells. The B cells are responsible for making antibodies to attach to the antigen. Complement
is a protein made in the liver that coats an offending organism or cell to stimulate phagocytic
cells to digest the cell or organism. Human leukocyte antigens are protein markers on the cell
wall of white blood cells that inform the immune system if a cell belongs to the system or
should be removed.
17. The nurse is studying the process whereby antibodies are made in the body. If the body
immediately responds to an offending organism, this means the body:
1. Has been exposed before and responds with secondary immunity.
2. Has an overproduction of plasma cells.
3. Is unable to differentiate self from non-self.
4. Has immune tolerance.
Answer: Has been exposed before and responds with secondary immunity.
Rationale:
B cells must be activated or told to make specific antibodies. If a B cell recognizes an antigen
and immediately makes antibodies, this means the body has been exposed to the organism
before and responds with secondary immunity. Plasma cells are B cells found in the plasma
and make a group of antibodies called immunoglobulins. The inability to differentiate self
from non-self is a considered a lack of immune tolerance. Immune tolerance is defined as the
ability of the immune system to tolerate all self antigens while retaining the ability to have an
effective immune response to non-self antigens.
18. A patient tells the nurse that this illness is “much less” than the last one he had. The nurse
realizes this patient is describing:
1. A secondary immune response.
2. A primary immune response.
3. An inflammatory response.
4. Natural immunity.
Answer: A secondary immune response.
Rationale:
A secondary immune response is the body’s response to an antigen that it has been exposed to
in the past. The response is stronger and can be instantaneous or occur within 1 to 3 days. A
primary immune response is the body’s first exposure to an antigen and can take 4 to 8 days
for the body to respond and make memory B cells. An inflammatory response is the body’s
response to an injury or offending organism that leads to a histamine release and local
responses of redness, edema, pain, and heat. Natural immunity provides protection from
foreign proteins, chemicals, and other non-self particles that are present at birth or shortly
thereafter.
19. A 68-year-old patient tells the nurse that he does not understand why he has been
experiencing more colds over the last several years. The nurse realizes the most likely reason
for experiencing more illness is that:
1. There is a decrease in the number and function of T cells.
2. There is a faster response by the B cells.
3. There is a decrease in complement.
4. The flu vaccine does not work as well in the elderly.
Answer: There is a decrease in the number and function of T cells.
Rationale:
The decline in T cell number and function with aging results in greater susceptibility to
infection. The B cells have a slower response as a person ages. There is no evidence to
suggest a change in the amount or function of complement. There is no evidence to suggest
that the flu vaccine does not work well in the elderly.
20. The mother of a premature newborn asks the nurse why she needs to wear a protective
gown, gloves, and mask when holding her baby. Which of the following is the nurse’s best
response to this mother?
1. “It is because the baby might not have enough immunity since she was born premature.”
2. “It is because the baby is in an incubator.”
3. “It is to protect you from picking up an infection from the hospital environment.”
4. “It is to protect your clothing from accidental spills.”
Answer: “It is because the baby might not have enough immunity since she was born
premature.”
Rationale:
The major protection of the newborn against antigens occurs through the transfer of maternal
immunoglobulin G antibodies across the placenta, especially during the last weeks of
pregnancy. Infants born prematurely may be significantly immune deficit. The protective
clothing is not worn because the baby is in an incubator, to protect the mother from picking
up an infection, nor to protect the mother’s clothing from accidental spills.
21. The parent of an adolescent tells the nurse that her adolescent child is experiencing an
increase in colds over the last months. The nurse realizes that this patient might be
experiencing:
1. The result of an incompetent thymus gland during infancy and childhood.
2. Poor personal hygiene.
3. Inadequate intake of nutrients.
4. Stress-related illnesses.
Answer: The result of an incompetent thymus gland during infancy and childhood.
Rationale:
The thymus contributes to immune development because it generates mature
immunocompetent T lymphocytes during infancy and childhood. By puberty, the thymus
atrophies and is replaced by adipose tissue. The adolescent’s thymus gland is atrophying,
which means he might not have developed sufficient T cells during infancy and childhood.
There is no evidence to suggest the adolescent has poor personal hygiene, has an inadequate
intake of nutrients, or is experiencing stress-related illnesses.
22. The nurse is assessing a patient who appears fatigued, pale, and says that he has lost 15
pounds over the last month. This information suggests to the nurse that the patient:
1. Should be further assessed for the presence of a malignancy.
2. Is having financial difficulty.
3. Is depressed.
4. Has a change in taste and smell and has probably lost interest in food.
Answer: Should be further assessed for the presence of a malignancy.
Rationale:
While inspecting the patient, the nurse sees a fatigued and pale patient with a 15-pound
unintentional weight loss over the last month. This information is serious and the patient
should be further assessed for the presence of a malignancy. There is not enough information
for the nurse to determine that the patient is having financial difficulty or that the patient is
depressed. The nurse also does not know at this time if the patient has had a change in taste
and smell.
23. The nurse is having difficulty palpating the inguinal lymph nodes of a patient. Which of
the following does this finding indicate to the nurse?
1. Lymph is draining appropriately without evidence of infection or inflammation.
2. The patient has a systemic infection and needs further assessment.
3. The patient will develop lymph edema in the coming years.
4. The inguinal lymph nodes are not functioning appropriately.
Answer: Lymph is draining appropriately without evidence of infection or inflammation.
Rationale:
Normally, inguinal lymph nodes are small, mobile, and difficult to palpate. The nurse is not
able to palpate the patient’s inguinal lymph nodes, which means lymph is draining
appropriately without evidence of infection or inflammation. There is no evidence to suggest
the patient has a systemic infection and needs further assessment, that the patient will develop
lymph edema in the coming years, or that the patient’s lymph nodes are not functioning
appropriately.
24. While percussing a patient’s left lung, the nurse detects a change in the sound of the lung
tissue to dull. Which of the following does this finding most likely suggest to the nurse?
1. The patient might have fluid in the lung, which could indicate an infection.
2. The patient has a mass in his lung.
3. The patient has emphysema.
4. The patient has congestive heart failure.
Answer: The patient might have fluid in the lung, which could indicate an infection.
Rationale:
Percussion over the lungs is done to determine if fluid is present that would change the
normal resonant sound of the lung tissue to a dull sound that may indicate an infection. There
is not enough information to determine if the patient has lung mass, emphysema, or
congestive heart failure.
25. A patient is admitted for an infected leg wound. The nurse notes that the patient’s band
count on the CBC and differential is elevated. This finding would indicate which of the
following?
1. The patient could be developing sepsis.
2. The patient is healing.
3. The leg wound is caused by a parasite.
4. The patient has lymphoma in addition to a leg wound.
Answer: The patient could be developing sepsis.
Rationale:
Bands are immature neutrophils that, when elevated, indicate a large bacterial infection or
sepsis. Elevated bands do not mean that the patient is healing. If the wound were caused by a
parasite, the eosinophils would be elevated. Lymphocytes are elevated in a patient diagnosed
with lymphoma in addition to an infection. This patient’s bands were elevated.
26. The results of a patient’s ELISA test were positive. The nurse realizes that:
1. The patient will next have the Western blot test done.
2. The patient is HIV positive and will need to begin treatment.
3. The patient is not HIV positive.
4. The patient has an acute inflammatory process somewhere in the body.
Answer: The patient will have the Western blot test done.
Rationale:
When the ELISA test is positive for HIV, the Western blot test will be done because it is more
sensitive for HIV. The Western blot test will be done before the definitive diagnosis of HIV is
made. At this time, the patient’s HIV status is not confirmed. These tests are done to diagnose
HIV and not acute inflammation.
27. The nurse is analyzing a patient’s complete blood count. Which of the following results
would indicate the presence of an infection?
1. Lymphocytes 45%
2. Neutrophils 58%
3. Basophils 0.4%
4. Eosinophils 1%
Answer: Lymphocytes 45%
Rationale:
A normal lymphocyte count is between 20% and 30%. Elevations could indicate the presence
of an infection. The remainder of the values are within normal limits.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
