Test Bank For High Acuity Nursing 5th Edition Kathleen Wagner

Test Bank for High-Acuity Nursing, 5th Edition: Kathleen Wagner
Test Bank for High-Acuity Nursing, 5th Edition:

Kathleen Wagner
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Wagner
Module 7 – Alterations in White Blood Cell Function
Learning Objectives
7-1. Discuss the etiology, pathophysiology, clinical manifestations, and management of

neutropenia.
7-2. Explain the theoretical concepts of the hypersensitivity and autoimmune disorders.
7-3. Discuss the etiology, pathophysiology, clinical manifestations, and management of

leukemia.
7-4. Discuss human immunodeficiency virus (HIV) and acquired immunodeficiency

syndrome (AIDS).
7-5. Describe the effects of aging, malnutrition, stress, and trauma related to the functions
of the adult immune system.
7-6. Discuss nursing considerations pertinent to the assessment and care of the
immunocompromised patient.
©2010 by Pearson Education, Inc.

Wagner/Johnson/Hardin-Pierce, Test Item File for High-
Acuity Nursing, 5th Edition
LO: 7-1. Discuss the etiology, pathophysiology, clinical manifestations, and management
of neutropenia.
1. The nurse is caring for a patient who is demonstrating signs of neutropenia. Which of
the following would contribute to this health problem?
1. vitamin C deficiency
2. untreated bacteria infection
3. bone marrow suppression after chemotherapy
4. diabetes mellitus
Answer: 3
Rationale: Neutropenia caused by decreased production of neutrophils can occur as a

result of bone marrow suppression after chemotherapy. It can also occur with a vitamin
B12 deficiency and not a vitamin C deficiency. Untreated bacterial infections are not
known to cause neutropenia. Diabetes mellitus does not cause neutropenia.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Physiological Integrity

of neutropenia.
2. A patient with neutropenia develops a fever. Which of the following should the nurse
do to support this patient?
1. Encourage fluids.
2. Report the finding and prepare to implement interventions to reduce the infection.
3. Document the finding and trend other episodes of temperature elevation.
4. Monitor the temperature every 1 hour.
Answer: 2
Rationale: Febrile neutropenia is a potentially life-threatening event and must be treated

rapidly. The nurse should do more than encourage fluids. Documenting the finding and
trending for other episodes of temperature elevation will not help the patient since this is
a life-threatening event. Monitoring the temperature every 1 hour might be applicable but
the nurse should report the finding and prepare to implement interventions to help reduce
the infection.
Cognitive Level: Applying
Nursing Process: Implementation

of neutropenia.
3. A patient is prescribed Neupogen. The nurse should do which of the following when
preparing to administer to this patient?
1. Allow the medication to warm to room temperature for no longer than 6 hours.
2. Withdraw prescribed amount and return remaining medication to refrigerator for
later use.
3. Discard vial if left at room temperature for longer than 4 hours.
4. Prepare the medication for intramuscular injection.
Answer: 1
Rationale: The medication must be used within 6 hours if left at room temperature. If not
used, the medication should be discarded. This is a measure to reduce contamination and
bacterial growth. Each vial is a one-time use therefore any unused medication in a vial is
not to be saved or returned to the refrigerator for later use. The medication is
administered either through subcutaneous injection or through an intravenous access line.

LO: 7-2. Explain the theoretical concepts of the hypersensitivity and autoimmune
disorders.
1. A patient receiving a blood transfusion begins gasping for breath 10 minutes into the
transfusion. The nurse realizes the patient is experiencing
1. a type I hypersensitivity response.
2. a type III hypersensitivity response.
3. a type IV hypersensitivity response.
4. a type II hypersensitivity response.
Answer: 4
Rationale: A transfusion reaction is a major example of a type II hypersensitivity

response. The reaction will occur within minutes of beginning the transfusion and is an
emergency. A type I hypersensitivity response occurs after repeated exposure to an
allergen which causes an allergen-antigen response. A type III hypersensitivity response
is also an allergen-antigen response however the complexes are found in tissues. Organ
rejection is an example of this type of response. A type IV hypersensitivity response is a
delayed response seen after an insect bite or with poison ivy.

disorders.
2. A patient, recovering from skin grafts to the arm because of burn injuries, is
demonstrating an increase of drainage, bleeding, and edema. The nurse realizes the
patient is experiencing which of the following?
1. serum sickness
2. Arthus reaction
3. type I hypersensitivity reaction
4. type IV hypersensitivity reaction
Answer: 2
Rationale: The arthus reaction is a localized skin reaction in which antigen-antibody

complexes form in vessel walls, triggering an inflammatory response in the vessels. The
reaction onset is relatively rapid, usually within one hour of exposure, and peaks within 6
to 12 hours. The clinical manifestations are those caused by the inflammatory response
and include leaking of fluid causing edema and hemorrhage. Serum sickness is a systemic
type III hypersensitivity response. A type I hypersensitivity reaction occurs after repeated
exposure to an allergen which causes an allergen-antigen response. A type IV
hypersensitivity reaction is a delayed response seen after an insect bite or with poison
ivy.

disorders.
3. A patient tells the nurse that he had a tuberculin test several months ago and the site
of injection became very red and inflamed. The nurse realizes this patient experienced
a(n)
1. Arthus reaction.
2. type I hypersensitivity response.
3. type IV hypersensitivity response.
4. type II hypersensitivity response.
Answer: 3
Rationale: A type IV hypersensitivity response is seen in the induration of a positive

tuberculin test. An Arthus reaction is a localized skin reaction in which antigen-antibody
complexes form in vessel walls, triggering an inflammatory response in the vessels. A
type I hypersensitivity response occurs after repeated exposure to an allergen which
causes an allergen-antigen response. A type II hypersensitivity response is considered a
hemolytic reaction. Transfusion reaction is a major example of this type of
hypersensitivity in addition to drug reaction-induced hemolytic anemia, and
hyperthyroidism caused by Graves’ disease.

disorders.
4. A patient with an autoimmune disorder asks the nurse for the cause of the problem.
Which of the following should the nurse respond with to this patient?
1. It happens when you have a chronic illness.
2. It’s because you were exposed to something repeatedly and then the body decided
it needed to destroy it.
3. Your body misinterprets normal cells as being foreign and attempts to destroy
them.
4. It happens when there is a vitamin deficiency.
Answer: 3
Rationale: One theory about autoimmunity is that of molecular mimicry. This is when the
body will react appropriately to an allergen but then incorrectly identifies normal body
tissue as being the same allergen and begins to destroy normal tissue. This is what the
nurse should respond with to the patient. Autoimmune disorders are not linked
specifically to chronic illnesses. Autoimmune disorders do not occur in response to
repeated exposure to an allergen. Autoimmune disorders are not specifically linked to
vitamin deficiencies.

of leukemia.
1. The blood sample from a patient’s bone marrow biopsy included Auer rods. The nurse
realizes this finding is consistent with
1. acute myelogenous leukemia.
2. acute lymphocytic leukemia.
3. chronic lymphocytic leukemia.
4. chronic myelogenous leukemia.
Answer: 1
Rationale: An examination of peripheral blood and the bone marrow in a patient with
acute myelogenous leukemia might include Auer rods which are abnormally large
granule-containing needle-like rods in the cytoplasm. These rods are most commonly
found in blast cells taken from the bone marrow and blood from patients with acute
myelogenous leukemia. Auer rods are not associated with acute or chronic lymphocytic
or chronic myelogenous leukemia.

of leukemia.
2. A patient in the chronic phase of chronic myelogenous leukemia has just completed
treatment. The nurse realizes this patient will most likely
1. be cured.
2. enter the accelerated phase within one year.
3. have a life expectancy of a few months.
4. remain in the chronic phase for five or more years.
Answer: 4
Rationale: There are three phases of chronic myelogenous leukemia: chronic, accelerated,
and acute. After treatment while in the chronic phase, the patient will most likely remain
in this phase for five or more years. Treatment in the chronic phase does not cure the
disease. Because the patient received treatment in the chronic phase, the accelerated
phase will be delayed for over five years. A life expectancy of a few months is seen in
those patients in the acute phase of the disease.

of leukemia.
3. A patient with leukemia begins to have seizures. The nurse realizes that the onset of
seizure activity is because of
1. pancytopenia.
2. malignant cell expansion.
3. hemodynamic instability.
4. infiltration into the central nervous system.
Answer: 4
Rationale: Signs and symptoms of infiltration into the central nervous system include
headache, nausea, vomiting, seizures, and coma. Signs and symptoms of pancytopenia
include frequent infections, fevers, bleeding gums, and fatigue. Signs and symptoms of
malignant cell expansion include bone tenderness or pain and impaired circulation.
Hemodynamic instability is not considered a category for the signs and symptoms of
leukemia.

of leukemia.
4. A patient with acute myelogenous leukemia is scheduled for a hematopoietic stem-cell

transplant. The treatment goal for this patient would be
1. cure.
2. remission from the disease for at least 5 years.
3. prolong the chronic phase of the disease for at least 10 years.
4. shorten the acute phase of the disease.
Answer: 1
Rationale: For some disorders such as acute myelogenous leukemia, hematopoietic stem-
cell transplant is the only potential curative option. The use of hematopoietic stem-cell
transplantation will not place the patient in remission but will attempt to cure the disease.
Acute myelogenous leukemia does not have the stages of chronic or acute.
Nursing Process: Planning

LO: 7-4. Discuss human immunodeficiency virus (HIV) and acquired immunodeficiency
syndrome (AIDS).
1. A patient tells the nurse that he does not want to ever receive a blood transfusion
because he does not want to get HIV. With which of the following should the nurse
respond to this patient?
1. Transmission of HIV through blood products is so rare today because of blood
testing being done.
2. That is a valid concern.
3. There is no way to avoid the transmission of HIV.
4. HIV only is transmitted through high risk behavior such as using contaminated
needles.
Answer: 1
Rationale: The nurse should explain that because of sophisticated blood screening done in
the United States today, the transmission of HIV through blood products is rare. The
nurse should not support the patient by stating he has a valid concern. HIV can be
avoided. HIV is not only transmitted through high risk behavior but also sexual contact,
administration of contaminated blood products, and mother-to-fetus.
Client Need: Health Promotion and Maintenance

syndrome (AIDS).
2. A female patient is concerned after learning that a person, with whom she had a
casual sexual encounter, has been diagnosed as being HIV positive. Which of the
following should be explained to this patient?
1. An HIV positive status will manifest in a few months so all exposures will lead to
disease.
2. Be sure to be tested in one month to see if the disease was transmitted to you.
3. An individual may be exposed to the virus but neither carry nor contract the
disease.
4. I would not worry about it because you probably did not get enough of a viral
load.
Answer: 3
Rationale: There are three types of human-HIV relationships: exposure, carrier, and
terminal disease. The nurse should explain to the patient how an individual may be
exposed to the virus but neither carry nor contract the disease. Seroconversion takes from
6 to 14 months so suggesting that the patient be tested in one to a few months is incorrect.
Successful transmission also requires a sufficient viral load; that is, the amount of virus
that enters the blood. The nurse has no way of knowing the viral load the patient received
during exposure and should not tell the patient not to worry about it.

syndrome (AIDS).
3. A patient who is HIV positive has been diagnosed with AIDS because of
demonstrating signs of another illness. The illness this patient most likely is
experiencing would be
1. mononucleosis.
2. pneumocystis jiroveci pneumonia.
3. hepatitis C.
4. pancreatitis.
Answer: 2
Rationale: The most common AIDS-defining illnesses in the U.S. are Pneumocystis
jiroveci pneumonia, Cytomegalovirus, and Mycobacterium avium-intracellulare complex.
The diagnosis of AIDS is not made when being HIV positive and having the diagnoses of
mononucleosis, hepatitis C, or pancreatitis.

LO: 7-5. Describe the effects of aging, malnutrition, stress, and trauma related to the
functions of the adult immune system.
1. A 55-year-old patient tells the nurse that he seems to be getting “more colds” as he
gets older. Which of the following would explain what the patient is experiencing?
1. The thyroid gland begins to malfunction after the 4th decade of life.
2. The thymus gland shrinks, reducing the maturation and differentiation of T cells
needed to fight infections.
3. The immune system has difficulty determining self from non-self cells.
4. The body has difficulty recognizing mutated cells.
Answer: 2
Rationale: The function of the immune system declines with age. The thymus gland,
where T lymphocytes mature and differentiate, begins to atrophy early in life and
continues to shrink until a person reaches middle age. Although T lymphocytes continue
to be produced, their maturation and differentiation into the various functional T cells
decreases. This places the older patient at higher risk for increased frequency and severity
of infections accompanied by a decreased ability to resolve the infection. The thyroid
gland plays no significant role in immunity. The ability of the immune system to
discriminate between antigens that are “self” from those that are “non-self” would
explain the increased incidence of autoimmune diseases in middle age and older patients.
The body’s immune system becoming less efficient at recognizing and destroying
mutated cells can explain the increased incidence of cancer in the older adult.

2. An elderly patient, admitted with malnutrition, begins to demonstrate signs of

pneumonia. The nurse realizes this additional health problem can be because of
1. a lack of sufficient nutrients to support the normal functioning of the patient’s
immune system.
2. a deficiency of vitamin C.
3. a deficiency of thiamine.
4. insufficient fluid intake.
Answer: 1
Rationale: Malnutrition affects the immune system because calories and protein are
needed to form and maintain the T cells and immunoglobulins. Vitamins A, E,
pyridoxine, folic acid, and pantothenic acid and not vitamin C or thiamine, affect the
function of both T cells and B cells. An insufficient fluid intake could exacerbate the
symptoms of pneumonia but not cause the illness.

3. A patient tells the nurse that it seems like the only time she gets a cold is when she is
under higher than normal stress. The reason for the patient having colds is because of
1. cortisol suppressing the immune system and decreasing T and B cell response.
2. an inadequate intake of nutrients during periods of stress.
3. lack of rest and sleep.
4. an increase in T and B cell production leading to an autoimmune response.
Answer: 1
Rationale: Cortisol has a direct suppressing effect on the immune system by inhibiting
the production of interleukins which stimulate T and B cell production and response.
There is no evidence to suggest that the patient has an inadequate intake of nutrients
during periods of stress. There is also no evidence to support the patient is lacking sleep
or rest. Cortisol suppresses T and B cell production and response and does not increase
them.

LO: 7-6. Discuss nursing considerations pertinent to the assessment and care of the
1. The nurse is assessing a patient for altered immunocompetence. Which of the

following would indicate that the patient is at risk for developing an
immunocompetence-associated illness?
1. heart palpitations
2. heartburn and increased flatus
3. slow wound healing and easy bruising
4. bursitis and muscle cramps
Answer: 3
Rationale: Assessment data that could indicate an immunocompetence-associated illness

includes slow wound healing and easy bruising in addition to weight loss, mouth
ulcers/sores, fever, fatigue, and weakness. Heart palpitations, heartburn, flatus, bursitis,
and muscle cramps are not associated with immunocompetence related illnesses.

2. A patient with diabetes tells the nurse that she has been “fighting” a cold for several
weeks. Which of the following should the nurse consider for this patient?
1. inadequate caloric intake
2. immunocompromisation because of the diabetes
3. high blood glucose level
4. insufficient diabetes medication
Answer: 2
Rationale: The patient has diabetes and is “fighting” a cold for several weeks. This could
indicate a problem with immunity because a high-acuity patient is at high risk for
development of immunocompetence problems secondary to prolonged stress, severe
infections, malnutrition, diabetes, and other problems. There is not enough information to
determine if the patient has an inadequate caloric intake, a high blood glucose level, or
has not been prescribed sufficient diabetes medication.

Test Bank for High-Acuity Nursing, 5th Edition: Kathleen Wagner
3. The nurse is instructing a patient with a compromised immune status on the signs and
symptoms of infections. Which of the following should be included in these
instructions?
1. cloudy urine
2. increased sputum production
3. purulent wound drainage
4. irritated oral mucosa
Answer: 4
Rationale: The immunocompromised patient will not demonstrate a normal immune

response so clinical findings will be different. These patients will not be able to form pus
so common infection findings such as cloudy urine, increased sputum production and
purulent wound draining will not occur. Monitoring for infection should focus on the
mucous membranes, skin, and lungs, which are the most common sites of infection in this
patient population. The nurse should instruct the patient to suspect irritated oral mucosa
as a sign of infection.

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Module 7 – Alterations in White Blood Cell Function

7-1. Discuss the etiology, pathophysiology, clinical manifestations, and management of

7-3. Discuss the etiology, pathophysiology, clinical manifestations, and management of

7-4. Discuss human immunodeficiency virus (HIV) and acquired immunodeficiency

©2010 by Pearson Education, Inc.

Rationale: Neutropenia caused by decreased production of neutrophils can occur as a

Cognitive Level: Analyzing

Nursing Process: Assessment

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Rationale: Febrile neutropenia is a potentially life-threatening event and must be treated

Cognitive Level: Applying

Nursing Process: Implementation

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Cognitive Level: Applying

Nursing Process: Implementation

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Rationale: A transfusion reaction is a major example of a type II hypersensitivity

Cognitive Level: Analyzing

Nursing Process: Assessment

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Rationale: The arthus reaction is a localized skin reaction in which antigen-antibody

Cognitive Level: Analyzing

Nursing Process: Assessment

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Rationale: A type IV hypersensitivity response is seen in the induration of a positive

Cognitive Level: Analyzing

Nursing Process: Assessment

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Cognitive Level: Applying

Nursing Process: Implementation

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Cognitive Level: Analyzing

Nursing Process: Assessment

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Cognitive Level: Analyzing

Nursing Process: Assessment

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Cognitive Level: Analyzing

Nursing Process: Assessment

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

4. A patient with acute myelogenous leukemia is scheduled for a hematopoietic stem-cell

Cognitive Level: Analyzing

Nursing Process: Planning

Client Need: Physiological Integrity

©2010 by Pearson Education, Inc.

Cognitive Level: Applying

Nursing Process: Implementation

Client Need: Health Promotion and Maintenance

©2010 by Pearson Education, Inc.