Chapter 17: Inflammation and Immunity

Chapter 17: Inflammation and Immunity

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. The student nurse learns that the most important function of inflammation and immunity is which purpose?
   1. Destroying bacteria before damage occurs
   2. Preventing any entry of foreign material
   3. Providing protection against invading organisms
   4. Regulating the process of self-tolerance

ANS:   C

The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.

DIF:     Remembering/Knowledge                 REF: 275                     KEY: Immunity| inflammation| infection control                                              MSC: Integrated Process: Teaching/Learning                       NOT:                                                 Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse is assessing an older client for the presence of infection. The client’s temperature is 97.6° F (36.4° C). What response by the nurse is best?
   1. Assess the client for more specific signs.
   2. Conclude that an infection is not present.
   3. Document findings and continue to monitor.
   4. Request that the provider order blood cultures.

ANS:   A

Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

DIF:     Applying/Application                         REF: 277                     KEY: Infection| inflammation| immunity| older adult| nursing assessment  MSC:                             Integrated Process: Nursing Process: Assessment                                       NOT:                          Client Needs Category: Health Promotion and Maintenance

3. A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important?
   1. “Avoid large crowds and people who are ill.”
   2. “Check over-the-counter meds for acetaminophen.”
   3. “Take this medicine exactly as prescribed.”
   4. “You have a higher risk of developing cancer.”

ANS:           A

Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

DIF:            Understanding/Comprehension         REF:    287                   KEY: Inflammation| immunity| infection control| client teaching                            MSC: Integrated Process: Teaching/Learning          NOT:          Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
   1. Assessing vaccination records for booster shot needs
   2. Encouraging the client to eat a nutritious diet
   3. Instructing the client to wash minor wounds carefully
   4. Teaching hand hygiene to prevent the spread of microbes

ANS:           A

Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

DIF:            Understanding/Comprehension         REF:    277                   KEY: Immunity| inflammation| older adult| vaccinations                                         MSC: Integrated Process: Nursing Process: Assessment                      NOT:                                                 Client Needs Category: Health Promotion and Maintenance

5. A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
   1. Noticeable rubor
   2. Purulent drainage
   3. Swelling and pain
   4. Warmth at the site

ANS:           B

During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

DIF:            Remembering/Knowledge                 REF:    281                   KEY: Inflammation| immunity| inflammatory response| nursing assessment MSC:           Integrated Process: Nursing Process: Assessment                      NOT:                                                 Client Needs Category: Physiological Integrity: Reduction of Risk Potential