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[Osborn ]chapter 59

Learning Outcomes [Number and Title]


Learning Outcome 1
Describe the general function of the organs, tissues, and cellular
components of the immune system.
Learning Outcome 2
Compare and contrast the significance of self antigens versus
non-self antigens and immune tolerance.
Learning Outcome 3
Compare and contrast cell-mediated and humoral immunity in
relationship to the type of lymphocytes involved, response to
antigens, and role in immune protection.
Learning Outcome 4
Compare and contrast the actions of cytokines, lymphokines,
interleukins, interferons, complement, and tumor necrosis factor
on immune function.
Learning Outcome 5
Explain the action and significance of acquired immune
response through immunizations.
Learning Outcome 6
Explain the action and significance of antigen presentation in Bcell activation, stimulation of immunoglobulin production, and
secondary immune response.
Learning Outcome 7
Discuss the effects of aging on the immune system.
Learning Outcome 8
Apply the assessment skills of inspection, palpation, percussion,
and auscultation in evaluating body systems and determining
the status of immune function.
Learning Outcome 9
Interpret and relate immune-related laboratory tests when
assessing immune function.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

Basophil.
Neutrophil.
Eosinophil.
Monocyte.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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 nurses best response to this patient?
1. Bacteria are always present on the skin, and too much hand washing could lead
to skin breakdown.
2. Thats 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 cant grow on the skin, so the hand washing is not needed.
Correct Answer: Bacteria are always present on the skin, and too much hand washing
could lead to skin breakdown.
Cognitive Level: Skin is a barrier to bacteria and other organisms, preventing the entry
into the body. Skin is capable of inhibiting bacterial growth; however, bacteria are always
present on the skin surface in various quantities. Hand washing has been known to reduce
the amount of bacteria on the skin, but the nurse should counsel the patient that too much
hand washing can lead to skin breakdown. Instructing the patient to apply antibiotic
ointment to the skin does not directly address the patients continual hand washing.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

The presence and shape of toll receptors in the cells.


The importance of an alkaline environment in the stomach.
The role of skin in killing bacteria.
The need to retain the tonsils and adenoids.

Correct 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.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

4. A patient is admitted with an autoimmune disorder. The nurse realizes this disorder
occurs when the body:
1.
2.
3.
4.

Does not recognize self receptors.


Does not recognize non-self receptors.
Does not have enough white blood cells to combat infections.
Has an overproduction of histamine.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

Intact functioning MHC receptors.


An overabundance of white blood cells.
An enlarged spleen.
Engorged lymph nodes.

Correct 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 patients 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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 babys 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.
Correct Answer: Eliminate exposure to known carcinogens so that the babys 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.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

7. A patient tells the nurse that hes 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
patients illness
2. T-helper 1 stimulation to kill unidentified cells
3. Proliferation of CD 8 cells
4. Release of cytokines
Correct Answer: T-helper 2 memory of a previous exposure to the same virus that caused
the patients 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 patients 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

8. The nurse is caring for patient who has a lung infection, resulting in elevated
____________ levels in this patient.
1.
2.
3.
4.

Immunoglobulin A
Immunoglobulin M
Immunoglobulin E
Immunoglobulin D

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

9. While studying the antibodyantigen response, the nurse realizes that an antibody can
receive different types of antigens to protect the body from illness and disease. The
bodys ability to conform to the different antigens is considered:
1.
2.
3.
4.

Humoral immunity.
Cell-mediated immunity.
Immune tolerance.
Natural immunity.

Correct 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 systems
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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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 patients
body to fight this infection?
1.
2.
3.
4.

Interferon
Tumor necrosis factor
Tissue factor
Interleukin

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

11. A patient is admitted with liver cirrhosis. The nurse realizes that this patients
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.
Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

12. While reviewing a patients 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.
Correct 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.
Cognitive Level: Analysis
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

13. The parent of a young patient asks the nurse why her child should receive the
measles-mumps-rubella vaccination. Which of the following is the nurses 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.
Correct 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 parents 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.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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 nurses 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 bodys
immune response to the disease.
2. Of course you have protection against the disease.
3. Smallpox has been eradicated, so theres nothing to worry about.
4. Theres little chance that you will be exposed to smallpox now.
Correct 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 bodys
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 patients fears by
saying that smallpox has been eradicated or by saying that theres little chance that she
will be exposed to smallpox now.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

The child would have benefited from receiving the pneumococcal vaccine.
The child would have benefited from receiving the annual flu vaccination.
The child has outstanding natural immunity.
The child has escaped unnecessary pain from the immunizations.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

Intact functioning T cells


Intact functioning B cells
Complement
Functioning human leukocyte antigens

Correct 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.
Cognitive Level: Analysis
Client Need: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

Has been exposed before and responds with secondary immunity.


Has an overproduction of plasma cells.
Is unable to differentiate self from non-self.
Has immune tolerance.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Evaluation
Client Need: Health Promotion and Maintenance
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

A secondary immune response.


A primary immune response.
An inflammatory response.
Natural immunity.

Correct Answer: A secondary immune response.


Rationale: A secondary immune response is the bodys 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 bodys 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 bodys 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

There is a decrease in the number and function of T cells.


There is a faster response by the B cells.
There is a decrease in complement.
The flu vaccine does not work as well in the elderly.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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
nurses 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.
Correct 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 mothers clothing from
accidental spills.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

The result of an incompetent thymus gland during infancy and childhood.


Poor personal hygiene.
Inadequate intake of nutrients.
Stress-related illnesses.

Correct 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 adolescents 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

Should be further assessed for the presence of a malignancy.


Is having financial difficulty.
Is depressed.
Has a change in taste and smell and has probably lost interest in food.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 8

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

Lymph is draining appropriately without evidence of infection or inflammation.


The patient has a systemic infection and needs further assessment.
The patient will develop lymph edema in the coming years.
The inguinal lymph nodes are not functioning appropriately.

Correct 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 patients 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 patients lymph
nodes are not functioning appropriately.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 8

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

24. While percussing a patients 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.
2.
3.
4.

The patient might have fluid in the lung, which could indicate an infection.
The patient has a mass in his lung.
The patient has emphysema.
The patient has congestive heart failure.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 8

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

25. A patient is admitted for an infected leg wound. The nurse notes that the patients
band count on the CBC and differential is elevated. This finding would indicate which of
the following?
1.
2.
3.
4.

The patient could be developing sepsis.


The patient is healing.
The leg wound is caused by a parasite.
The patient has lymphoma in addition to a leg wound.

Correct 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 patients bands
were elevated.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 9

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

26. The results of a patients ELISA test were positive. The nurse realizes that:
1.
2.
3.
4.

The patient will next have the Western blot test done.
The patient is HIV positive and will need to begin treatment.
The patient is not HIV positive.
The patient has an acute inflammatory process somewhere in the body.

Correct 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 patients HIV status is not
confirmed. These tests are done to diagnose HIV and not acute inflammation.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 9

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.

27. The nurse is analyzing a patients complete blood count. Which of the following
results would indicate the presence of an infection?
1.
2.
3.
4.

Lymphocytes 45%
Neutrophils 58%
Basophils 0.4%
Eosinophils 1%

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 9

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
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