Chapter 31: Immunologic System Introduction

Linton: Medical-Surgical Nursing, 7th 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. 554 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. 554 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. 557 OBJ: 1

TOP: Functions of the Immune System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. 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. 566 OBJ: 5

TOP: Insomnia with Steroids KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

5. 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 patient’s 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. 561 OBJ: 3

TOP: Preparation for Diagnostic Tests KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

6. After a bone marrow transplant, a patient is placed on a protocol of chemotherapy and

radiation and has the potential for injury. 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. 567 OBJ: 4

TOP: Bone Marrow Transplantation Risk
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. 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. 567 OBJ: 4

TOP: Bone Marrow Complications KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

8. 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. 555 OBJ: 1

TOP: Functions of the Spleen KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. 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 a
cause for concern.

DIF: Cognitive Level: Comprehension REF: p. 562 OBJ: 3

TOP: Platelet Count KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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

DIF: Cognitive Level: Knowledge REF: p. 566 OBJ: 3

TOP: Bone Marrow Transplantation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

11. 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. 555 OBJ: 1

TOP: Innate Immunity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. 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. 561 OBJ: 3

TOP: Skin Testing Procedure KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

1. What are the four distinct stages of the inflammatory process? (Select all that apply.)
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. 556 OBJ: 1

TOP: Stages of Inflammatory Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

1. 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. 555 OBJ: 1
TOP: Thymus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. 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. 553 OBJ: 1

TOP: Adult Stem Cells KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A