Chapter 15: Care of the Patient with an Immune Disorder

Chapter 15: Care of the Patient with an Immune Disorder

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. Which of the following is an example of immunocompetence?

ANS:  C

Immunocompetence is demonstrated by the immune system responding appropriately to a foreign stimulus and the body’s integrity is maintained as with cold symptoms that resolve with residual illness.

DIF:    Cognitive Level: Application           REF:   Page 737        OBJ:   1

TOP:   Immunocompetence                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

2. An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse’s first intervention?

ANS:  B

Provision of oxygen is the initial primary intervention. Anaphylaxis may advance very rapidly and the patient may have to be intubated. Covering the patient with a warm blanket is not wrong, but not an initial intervention.

DIF:    Cognitive Level: Application           REF:   Page 746        OBJ:   6

TOP:   Anaphylactic reaction                      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

3. What is the etiology of autoimmune diseases based on?

ANS:  D

Autoimmune disorders are failures of the tolerance to “self.” B and T cells produce autoantibodies that can cause pathophysiologic tissue damage. Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish “self” protein from “foreign” protein.

DIF:    Cognitive Level: Application           REF:   Page 749        OBJ:   1

TOP:   Autoimmune disorders                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

4. A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing plan of care should include provisions for:

ANS:  A

Immune deficient persons are at risk for infection and need to be protected aggressively for contagion.

DIF:    Cognitive Level: Application           REF:   Page 748        OBJ:   10

TOP:   Immunodeficiency diseases             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment

5. The nurse takes into consideration that when the antigen and antibody react, the complement system is activated which:

ANS:  C

The complement system is a group of plasma proteins that are dormant until there is an antigen-antibody interaction. The proteins destroy the cell membrane and attract phagocytes.

DIF:    Cognitive Level: Application           REF:   Page 741        OBJ:   3

TOP:   Complement system                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity