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128 Cards in this Set

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What are the chemical markers or flags that identify cells or molecules?
Antigens
What are the three types of lymphocytes?
natural killer (NK) cells
thymus- derived lymphocytes (T cells)
bone marrow– derived lymphocytes (B cells)
Where are the natural killer (NK) cells found?
in the blood, red bone marrow, lymph nodes, and spleen
What do the natural killer (NK) cells do?
They destroy many kinds of infected body cells and tumor cells.
What are the lymphocytes called T cells and B cells are involved in?
specific immune responses
What are called immunoglobulins (Ig) or gamma globulins?
Antibodies
What are the two mechanisms of immunity?
cell-mediated and
humoral immunity
What does cell-mediated immunity involve?
T cells
What does humoral immunity involve?
mainly B cells but is assisted by T cells
IgG is where
Blood, extracellular fluid, lymph
IgG's function is?
Crosses the placenta to provide passive immunity in newborns for the first three mo. of life
and
Provides long-term immunity following a vaccination or illness recovery
IgA is where?
External secretions ( e. g., tears, saliva)
IgA's function is?
Provides passive immunity for breastfed infants
and
Found in secretions of all mucous membranes
IgM is where?
Blood, lymph
IgM's function is?
Produced first during an infection (IgG production follows)
IgD is where?
B cells
IgD's function is?
Are antigen-specific receptors on B lymphocytes
IgE is where?
Mast cells or basophils
IgE's function is?
Important in allergic reactions
and
Mast cells release histamine
In Cell-Mediated Immunity, Cytotoxic T (or NK) cells are able to?
lyse infected body cells, malignant cells, or transplanted tissues
In an antibody response, what is the first exposure?
a foreign antigen stimulates antibody production
In an antibody response, what is the second exposure?
the memory cells begin rapid production of large amounts of antibody
What is the basis for the protection given by vaccines?
antibody responses
What are the two categories of immunity?
Passive immunity or Active immunity
What are some forms of natural immunity?
placental transmission of antibodies from mother to fetus
and
transmission of antibodies in breast milk
What is a form of artifical immunity?
injection of preformed antibodies
What type of immunity is when a person produces his or her own antibodies?
Active immunity
What type of immunity is when antibodies are not produced by the person but obtained from another source?
Passive immunity
Who is most susceptible to infection and autoimmune disorders?
older adults
What test do you run for a confirmation test for HIV?
Western Blot
What is a diagnostic procedure for the immune system?
MRI
What is something you should ask your patient if they are getting a MRI with contrast?
Ask them if they have an iodine allergy
What problem with an MRI would you need to notify the Physician?
Inform the Physician if your patient needs:

constant monitoring
IV equipment
who has implanted metal objects
who is agitated or claustrophobic
What is one thing you should always ask your patient?
If they have any allergies
If your patient has allergies, what should they wear?
a medical alert bracelet
What is it called when they prepare an extract of the allergen and injecting small amounts of it as a vaccine?
Immunotherapy
During immunotherapy, if the patient misses a dose what should you do?
Contact the Physician because the allergen strength may need to be reduced
1. The nurse who is teaching a patient about vaccines would be correct in teaching that a vaccine provides which of the following types of immunity?

a. Naturally acquired passive immunity
b. Artificially acquired passive immunity
c. Naturally acquired active immunity
d. Artificially acquired active immunity
d. Artificially acquired active immunity
2. Which of the following vaccines is recommended annually for the older patient?

a. Influenza
b. Pneumovax
c. Diphtheria tetanus
d. Polio
a. Influenza
3. The nurse is assisting with data collection. Which of the following past surgeries found in the history may influence immune system dysfunction?

a. Splenectomy
b. Thyroidectomy
c. Pneumonectomy
d. Parathyroidectomy
a. Splenectomy
4. During data collection, the patient reports tenderness in the cervical lymph nodes. The nurse recognizes that lymph nodes that are enlarged and tender usually indicate which of the following problems?

a. Cancer
b. Degeneration
c. Inflammation
d. Arthritis
c. Inflammation
5. The nurse is caring for a patient with suspected HIV. The nurse anticipates that which of the following is a confirmation test that will be ordered to test for HIV antibodies?

a. Murex SUDS
b. Western blot
c. Enzyme-linked immunosorbent assay
d. p24 antigen testing
b. Western blot
What is the most common form of allergy?
Allergic rhinitis
What are some antigens that cause allergic rhinitis?
pet dander, dust, rag weed
What is the treatment for allergic rhinitis?
eliminate the offending environmental stimuli
Eczema, is an inflammatory skin response or its called?
Atopic dermatitis
What is a SEVERE systemic type I hypersensitivity reaction called?
Anaphylaxis
What are some substances that commonly trigger Anaphylaxis?
Antibiotics, Food, Venoms
What is the pathophysiology of Anaphylaxis?
IgE antibodies produced from previous antigen sensitization are attached to mast cells throughout the body.
What are the S/S of Anaphylaxis?
It produces sudden, life-threatening S/S.

Stridor, wheezing, dyspnea, respiratory arrest, hypotension, & tachycardia are some of the S/S
What therapeutic measures do you take with Anaphylactic shock?
IV access is a priority for IV epinephrine
vasopressor drugs (dopamine)
fluids to increase BP &
O2 therapy is started
What type I hypersensitivity reaction is triggered by the antigen-stimulated reaction of IgE antibodies which release mast cell contents?
Urticaria (hives)
What are the S/S of Urticaria?
raised
pruritic
nontender
erythematous wheals on the skin
What therapeutic measures are done for Urticaria?
Corticosteroids or Antihistamines
What location on the body do the hives from Urticaria appear?
They tend to be concentrated on the trunk and proximal extremities.
What form of urticaria affects submucosal and subcutaneous tissues rather than the skin?
Angioedema
What should you monitor for in the Nursing Diagnosis of
Impaired Gas Exchange R/T Laryngeal Edema?
Monitor the patient for restlessness,
changes in mentation,
level of consciousness,
changes in voice,
dysphagia, or problems breathing
What would you teach in the Nursing Diagnosis of Ineffective Health Maintenance R/T Lack of Knowledge about Decreasing Inflamation and Pruritus and Reducing Episodes of inflamation?
Patients should avoid allergens:

have heating ducts cleaned
covering heat registers with filters
frequent home vacuuming and dusting
What would you teach your patients about Urticaria?
Teaching should include stress management and relaxation techniques and follow prescribed medications to relieve urticaria symptoms
What is the difference b/t Urticaria and Angioedema?
Both cause hives but Angioedema's eruptions
are deeper & the eruptions last longer than with urticaria.
What life threatening condition is when the recipient’s antibodies attach to the foreign antigens on the transfused RBCs, causing rapid lysis of the RBC?
Hemolytic Transfusion Reaction
What are the S/S of Hemolytic Transfusion Reaction?
sudden onset of low back (flank) or chest pain,
hypotension, fever rising more than 1.8° F,
chills, tachycardia, tachypnea, wheezing,
dyspnea, urticaria, and anxiety
What are some of the transfusion guidelines?
Two nurses:
1. double-checking the patient’s name & identification number on the chart
2. unit of blood
3. patient’s identification bracelet as well as
4. checking the patient’s blood type in the chart, on the unit of blood, and paperwork with the unit of blood.
Agency policy is followed for taking vital signs during a blood transfusion. Example times would be?
Before the blood transfusion to have a baseline,
15 min into the transfusion,
and when its complete.
How long should you stay with the patient after starting a transfusion?
Critical to stay with the patient at the bedside during the first 15 min
What are some medications that can be given in Hemolytic Transfusion Reactions?
Corticosteroids: decamethasone, metylprednisone, prednisone
What nursing implications are there when giving Corticosteroids?
Monitor patients weight because the Corticosteroids cause weight gain
What type III hypersensitivity immune reactions in which antigen- antibody complexes form and lodge in small vessels which leads to inflammation, tissue damage, and necrosis?
Serum Sickness
When does Serum Sickness occur?
after administration of penicillin or sulfonamide antibiotics
What are the S/S of Serum Sickness?
Severe Urticaria and Angioedema usually occurs 7 to 10 days after the exposure but it is self-limiting
What is the Type IV hypersensitivity reaction that occurs when a substance or chemical comes in contact with the skin?
Contact Dermatitis
What is it called when a form of transplanted living tissue is sensed as foreign material by the immune system?
Transplant Rejection
What is the greatest cause of death following a transplant?

What is needed to prevent tissue rejection after a transplant is done?
Infection

Lifelong Immunosuppression
What is Psychological consideration for nursing care of a Transplant patient?
Emotional support of patient and family due to loss of life to allow them the organ, allow them to express their feelings
What autoimmune disorder has antibodies that destroy gastric parietal cells lead to decreased production of intrinsic factor or Vit B12 absorption in the small bowel?
Pernicious Anemia
What is Pernicious Anemia caused by?
any type of gastric or small-bowel resections coupled with no or inadequate vitamin B12 or intrinsic factor replacement
What are the S/S of Pernicious Anemia?
weakness, loss of appetite,
glossitis (inflammation or infection of the tongue),
pallor, irritability, confusion,
numbness or tingling in the extremities (peripheral neuropathy)
What disorder for no known reason, has autoantibodies produced that attach to RBCs and cause them to either lyse or agglutinate (clump)?
Idiopathic Autoimmune Hemolytic Anemia
What are the S/S of Idiopathic Autoimmune Hemolytic Anemia?
mild fatigue and pallor to severe hypotension, dyspnea, palpitations, and jaundice
What diagnostic tests can you use for Idiopathic Autoimmune Hemolytic Anemia?
The RBC count, hemoglobin (Hgb), and hematocrit (Hct) are low and the lactate dehydrogenase (LDH) is elevated because of RBC destruction and tissue ischemia
What therapeutic measures are done for Idiopathic Autoimmune Hemolytic Anemia?
Folic acid (increase production of RBCs)
Immuno-suppressant meds & corticosteroids (useful in obtaining remission)
Erythrocytapheresis (process where abnormal RBCs are removed & replaced w/ normal RBCs)
severe cases - Splenectomy
What condition do autoantibodies for thyroid-stimulating hormone (TSH) form and enlarge the thyroid gland ?
Hashimoto’s thyroiditis
What are the three types of Lupus?
discoid, drug-induced, & systemic
lupus erythematosus
What is the etiology of Systemic Lupus Erythematosus?
young women of childbearing years and is more common in the African American and Hispanic populations
What are some S/S of Drug-Induced Lupus Erythematosus?
Pleuropericardial inflammation
Fever
Rash
Arthritis
What are some S/S of Systemic Lupus Erythematosus?
Butterfly rash, Arthritis,
Anemia, Pericarditis,
Myocardial Infarction, Renal,
Cognitive impairment, Seizures
What is the chronic progressive inflammatory disease that affects the large joints?
Ankylosing Spondylitis
Where does the inflammatory process of Ankylosing Spondylitis begin?
lower region of the back and progresses upward
What are the S/S of Ankylosing Spondylitis?
curvature of the lower back (lordosis) flattens & curvature of the upper back increases (kyphosis)
What medications used to treat LUPUS ERYTHEMATOSUS?
Antimalarials - chloroquine (Aralen)
or
Corticosteroids - dexamethasone (Decadron), prednisone (Deltasone)
What are the side effects of Antimalarials?
Gastric distress, anorexia, vomiting, diarrhea,
or blurred vision (teach pt if they have blurred vision to call physician)
What are the side effects of Corticosteroids?
Increased facial hair, acne, round “moon” face, mood changes, increased appetite, increased weight
How do you help reduce pain and stiffness in Ankylosing Spondylitis?
Explaining proper posture and range-of-motion exercises
Teaching to change positions frequently
Activity every couple of hours
What hereditary congenital disorder is characterized by the absence or deficiency of one or more of the five classes of immunoglobulins (IgG, IgM, IgA, IgD, and IgE) from a defective B-cell function?
Hypogammaglobulinemia
What therapeutic measures do you use for Hypogammaglobulinemia?
Injections of immunoglobulin.

These injections contain IgG, so fresh frozen plasma is given to replace IgM. IgA cannot be replaced, increasing the risk for frequent pulmonary infections.
1. A patient asks the nurse how an allergy can develop to a medication that has been taken before without problems. Which of the following is the most appropriate for the nurse to respond?

a. “It probably is due to your age, because as you age your body becomes more sensitive to environmental stimuli, which leads to hypersensitivities.”
b. “What have you eaten in the last 24 hours? Most medications are altered by food, thereby producing different effects in the body.”
c. “Viral illnesses and exposure to various chemicals and environmental substances can alter the immune system and its response to previously benign stimuli.”
d. “Patients who have autoimmune disorders such as lupus or arthritis tend to develop sensitivities to common medications.”
c. “Viral illnesses and exposure to various chemicals and environmental substances can alter the immune system and its response to previously benign stimuli.”
2. A patient asks the nurse what ankylosing spondylitis is. Which of the following responses is appropriate?

a. Chronic progressive inflammatory disease of large limb joints
b. Autoantibodies that lyse RBCs
c. Formation of antigen-antibody complexes leading to inflammation
d. Production of IgE antibodies
a. Chronic progressive inflammatory disease of large limb joints
3. Which of the following is a sign or symptom of pernicious anemia?

a. Glossitis
b. Itching
c. Kyphosis
d. Lower back spasms
a. Glossitis
4. What care would the nurse provide for a patient undergoing a Schilling test for pernicious anemia?

a. Maintain on bedrest.
b. Monitor vital signs.
c. Collect 24-hour urine specimen.
d. Maintain pressure dressing.
c. Collect 24-hour urine specimen.
5. Which of the following interventions should the nurse anticipate will be included in the treatment plan for a patient with allergic rhinitis? Select all that apply.

a. Antihistamines
b. Avoiding environmental stimuli
c. Immunotherapy
d. Steroids
e. Anticholinergics
f. Decongestants
a, b, c, d, f, all but e
6. Which data are collected when caring for a patient with contact dermatitis?

a. Date of gastric surgery
b. Appearance of skin lesions
c. Weight gain
d. Appetite
b. Appearance of skin lesions
7. A patient is admitted with an autoimmune disease and asks the nurse what autoimmune means. Which of the following would be the appropriate response by the nurse?

a. “ Immune cells produce too many antibodies.”
b. “ Immune cells grow and multiply too rapidly.”
c. “ Immune cells are not produced in sufficient amounts.”
d. “ Immune cells are unable to distinguish between ‘ self’ and ‘ not self.’”
d. “ Immune cells are unable to distinguish between ‘ self’ and ‘ not self.’”
8. A patient who has an allergy to penicillin is receiving pre-operative medications, which include ranitidine (Zantac), metoclopramide (Reglan), and cefazolin (Ancef) intravenously. Fifteen minutes after the cefazolin is started, the patient reports an uneasy feeling, as well as feeling very warm. The nurse would appropriately recognize that the patient is experiencing anaphylaxis and perform which of the following? Select all that apply.

a. Offer the patient ice water.
b. Discontinue the IV.
c. Stay with the patient.
d. Turn off the IVPB (piggyback).
e. Call for assistance.
f. Monitor vital signs.
c. Stay with the patient.
d. Turn off the IVPB (piggyback).
e. Call for assistance.
f. Monitor vital signs.
9. As a patient is being discharged after being diagnosed with SLE, the patient says that soon he is leaving on a 3-week tour of the Grand Canyon and going whitewater rafting. Which of the following patient statements conveys the patient’s understanding of the plan of care?

a. “ As long as I wear sunscreen, I’ll be fi ne in the sun.”
b. “ I’ll wear clothing on all exposed skin and use sunscreen.”
c. “ If I develop a rash, I should avoid the sun.”
d. “ I should avoid the sun in the morning.”
b. “ I’ll wear clothing on all exposed skin and use sunscreen.”
What is the best way to manage the HIV/AIDS epidemic?
Prevention and education (including the older school-age child, general population, and older adults
How is the HIV virus transmitted?
It is transmitted through blood, sexual secretions, or, for an infant with an infected mother, through fetal transmission or via breast milk
How is the HIV virus not transmitted?
It is not transmitted through insect bites, tears, nasal secretions, saliva, sweat, sputum, emesis, urine, or feces un-less blood is present
An AIDS patient that has lost more than 10% of baseline body weight, gastrointestinal (GI) infections, chronic diarrhea, for more than 30 days may have?
AIDS Wasting Syndrome
What is the fungus normally found in the GI tract that does not infect a person with a healthy immune system?
Candida albicans
In AIDS, overgrowth of this fungus occurs where?
mouth and esophagus
Opportunistic infections are a primary complication of HIV/AIDS, what is the most common of these that is a fungal infection that produces shortness of breath, fever, nonproductive cough, and fatigue?
Pneumocystis jiroveci Pneumonia
The diagnostic test CD4 and CD8 (cytotoxic cells) T lymphocytes is essential for evaluating the status of the immune system. The counts should be?
high (they are low as HIV/AIDS progresses) performed at 3-month intervals.
The diagnostic test called Viral load testing measures the amount of HIV RNA in plasma and we want the results to be?
low
Why is this test Viral load important?
1. important for determining the risk of disease progression
2. if left untreated, the risk of opportunistic infections
3. the response to antiretroviral therapy.
What therapeutic measures can be done for HIV/AIDS?
Because there is no cure the goal of therapy is to prevent or delay development of opportunistic diseases.
When should the HIV/AIDS patient be started on antiviral treatment?
When the CD4 count is < 350 cells/mm3 or the person has an AIDS-defining illness.
What is one Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) drug HIV/AIDS patients use?
nevirapine (Viramune)
What are the nursing implications for nevirapine (Viramune)?
Teach the patient to monitor for rash especially for the first month. (may be severe and life threatening)
How can caregivers stop opportunistic infections or the transmission of microorganisms with HIV/AIDS patients?
Caregivers should use standard precautions and strict aseptic technique for all patients and procedures
How can you reduce the exposure risk of HIV/AIDS patients and their pets?
Avoid pet feces/diarrhea
Pets should have up-to-date immunizations
Avoid those younger than 6 mo old
Avoid strays or exotic pets
What are S/S of Opportunistic Infections?
Teach p/t to monitor & report:
New fever higher than 100° F
Cough, shortness of breath, fever, or chest tightness (early signs of pneumonia)
1. The nurse would evaluate the patient as understanding modes of HIV transmission if the patient stated that the modes of HIV transmission include which of the following?

a. Saliva, tears, fecal-oral contamination
b. Close physical contact involving skin surfaces, mosquito bites
c. Sharing towels, sharing eating utensils, skin contact
d. Unprotected sex with HIV-infected partner, contact with infected blood products
d. Unprotected sex with HIV-infected partner, contact with infected blood products
2. The nurse is teaching a patient about HIV testing. Place HIV diagnostic tests in the sequential order in which they are performed.

a. Western blot test
b. Enzyme- linked immunosorbent assay (ELISA) test
c. Repeated ELISA test
b. c. a.
3. A patient who is newly diagnosed with HIV infection asks what to expect for future health status. The best response for the nurse to give is based on the understanding that HIV disease and AIDS are characterized as which of the following?

a. An acute disease
b. A life-ending disease
c. A chronically managed disease
d. A disease with remissions and exacerbations
c. A chronically managed disease
4. What should the nurse include in a teaching plan to prevent HIV infection? Select all that apply.

a. Recapping of used needles by caregiver permitted.
b. Abstain from sexual intercourse.
c. Avoid injection drug use.
d. Avoid use of male or female condoms.
e. Plan for autologous blood transfusion.
f. Test for HIV at time of labor.
b, c, e, f
5. Which of the following should the patient with HIV be taught to do to decrease risk of infections? Select all that apply.

a. Wash hands before eating.
b. Wash toothbrush.
c. Reuse dishes.
d. Buy prepared deli foods.
e. Report signs of infection.
f. May share razor with no visible blood.
a, b, e
6. The nurse would recognize that the patient needs further reinforcement of knowledge if the patient stated that one of the goals of antiretroviral therapy is which of the following?

a. Reduce the viral load.
b. Improve survival rates.
c. Decrease CD4 T lymphocytes.
d. Delay the progression of HIV disease.
c. Decrease CD4 T lymphocytes.
7. The nurse would recognize that the patient is having a reaction to delavirdine (Rescriptor) if which of the following occurred?

a. Rash
b. Edema
c. Abdominal pain
d. Blurred vision
a. Rash