Chapter 19: Inflammation and the Immune Response

Chapter 19: Inflammation and the Immune Response

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. A client has a reduction in immune function. What is the nurse’s priority action for this client?

a.	Determine whether it is temporary or permanent.
b.	Take the client’s vital signs every 4 hours.
c.	Teach family members to receive the flu shot yearly.
d.	Wash hands before entering the room.

 

 

ANS:  D

The nurse should take precautions to prevent infection in the client who has a reduction in immune function. It does not matter whether it is temporary or permanent. Teaching the family what to do after the client is discharged from the hospital would not be the primary action. Taking vital signs would be an important action but would not prevent infection, which is the priority.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Implementation)

 

2. Which client is at highest risk of compromised immunity?

a.	Client who has just had surgery
b.	Client with extreme anxiety
c.	Client who is awaiting surgery
d.	Client who just delivered a baby

 

 

ANS:  A

Intact skin is a defense to prevent infection; however, a client who has recently had surgery has a portal for organisms to enter the body and cause infection.

 

DIF:    Cognitive Level: Comprehension/Understanding               REF:   p. 303

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Assessment)

 

3. A client who has an extensive burn injury develops inflammation that covers the entire body. What is the nurse’s best action?

a.	Notify the health care provider immediately.
b.	Document the assessment.
c.	Take the client’s temperature.
d.	Ask for an order for antibiotic therapy.

 

 

ANS:  B

The inflammatory response depends on how severe the initiating event was. It would not be unexpected to have an extensive inflammatory reaction to a severe burn injury. The nurse would not have to notify the health care provider immediately, because this would not signal an emergency. This does not necessarily indicate a fever or an infection; however, the client with extensive burns would be prone to developing infection.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Implementation)

 

4. A client’s absolute neutrophil count (ANC) is 550/mm³. What is the nurse’s best action?

a.	Use Standard Precautions.
b.	Place the client on antibiotic therapy.
c.	Place client on a low-sodium diet.
d.	Administer chemotherapy.

 

 

ANS:  A

The ANC is low. The client who has a low ANC is at risk of developing infection. The client would not need to be started on antibiotic therapy, and a low-salt diet would not help the client. Administering chemotherapy would further lower the ANC and would not be appropriate.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC:  Integrated Process: Nursing Process (Implementation)