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Questions and Answers
Chickenpox is an example of which of the following types of immunities?
Chickenpox is an example of which of the following types of immunities?
Which of the following antibodies is involved with an anaphylactic reaction?
Which of the following antibodies is involved with an anaphylactic reaction?
The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with which of the following types of immunity?
The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with which of the following types of immunity?
Which of the following instructions should the nurse include when teaching a client with possible allergies about intradermal skin testing?
Which of the following instructions should the nurse include when teaching a client with possible allergies about intradermal skin testing?
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A chest x-ray can suppress immune function.
A chest x-ray can suppress immune function.
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Which of the following adverse effects should the nurse be aware of in a client with Goodpasture’s syndrome?
Which of the following adverse effects should the nurse be aware of in a client with Goodpasture’s syndrome?
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Which statement by a client on immunosuppressant therapy after a kidney transplant should alert the nurse that additional teaching is required?
Which statement by a client on immunosuppressant therapy after a kidney transplant should alert the nurse that additional teaching is required?
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Which adverse effect is related to cyclosporine administration?
Which adverse effect is related to cyclosporine administration?
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What is the most appropriate action in treating a client admitted to the hospital with an acute rejection of a kidney transplant?
What is the most appropriate action in treating a client admitted to the hospital with an acute rejection of a kidney transplant?
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What is the initial action for the nurse to take when a client is stung by a wasp and is experiencing difficulty breathing?
What is the initial action for the nurse to take when a client is stung by a wasp and is experiencing difficulty breathing?
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What is the priority action for the nurse to implement when a client complains of itching at the site of an intradermal allergen injection?
What is the priority action for the nurse to implement when a client complains of itching at the site of an intradermal allergen injection?
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What is the most appropriate action for the nurse to take when caring for a client experiencing an allergic reaction to an unknown allergen?
What is the most appropriate action for the nurse to take when caring for a client experiencing an allergic reaction to an unknown allergen?
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Which action should the nurse take first to determine if a client’s angioedema has responded to prescribed therapies?
Which action should the nurse take first to determine if a client’s angioedema has responded to prescribed therapies?
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What question should the nurse ask to determine possible causes of a hemoglobin of 200 g/L and a hematocrit of 54%?
What question should the nurse ask to determine possible causes of a hemoglobin of 200 g/L and a hematocrit of 54%?
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Which laboratory test should the nurse monitor for a client receiving heparin?
Which laboratory test should the nurse monitor for a client receiving heparin?
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What does a low mean corpuscular volume (MCV) indicate?
What does a low mean corpuscular volume (MCV) indicate?
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What lymph node finding should the nurse be most concerned about during physical assessment?
What lymph node finding should the nurse be most concerned about during physical assessment?
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What laboratory result should the nurse anticipate for a client with an intraoperative hemorrhage?
What laboratory result should the nurse anticipate for a client with an intraoperative hemorrhage?
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What actions should the nurse include in the care plan for a neutropenic client?
What actions should the nurse include in the care plan for a neutropenic client?
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What should the nurse monitor in the care plan for a client with a 'shift to the left' in complete blood count results?
What should the nurse monitor in the care plan for a client with a 'shift to the left' in complete blood count results?
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What action should the nurse take before an ultrasound of the spleen for a client in a car accident?
What action should the nurse take before an ultrasound of the spleen for a client in a car accident?
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For which diagnostic test should the nurse obtain a signed consent form for a client with pancytopenia scheduled for testing?
For which diagnostic test should the nurse obtain a signed consent form for a client with pancytopenia scheduled for testing?
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Which CBC information would be most important to communicate for a client with abdominal pain?
Which CBC information would be most important to communicate for a client with abdominal pain?
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Which of the following findings should the nurse identify as abnormal in a client's clotting study tests?
Which of the following findings should the nurse identify as abnormal in a client's clotting study tests?
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Which of the following information should the nurse include when discussing the EIA test results with a client who tested positive for HIV antibodies?
Which of the following information should the nurse include when discussing the EIA test results with a client who tested positive for HIV antibodies?
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According to the World Health Organization (WHO) diagnostic criteria, which diagnosis should the nurse anticipate for a client admitted with Pneumocystis jiroveci pneumonia (PCP) and positive HIV testing?
According to the World Health Organization (WHO) diagnostic criteria, which diagnosis should the nurse anticipate for a client admitted with Pneumocystis jiroveci pneumonia (PCP) and positive HIV testing?
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What action should the nurse implement for a client with a positive rapid-antibody test for HIV who is anxious and not attentive?
What action should the nurse implement for a client with a positive rapid-antibody test for HIV who is anxious and not attentive?
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What is the most appropriate response by the nurse to a client with AIDS expressing thoughts about dying?
What is the most appropriate response by the nurse to a client with AIDS expressing thoughts about dying?
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What information should the nurse include when teaching a pregnant woman with early chronic HIV infection?
What information should the nurse include when teaching a pregnant woman with early chronic HIV infection?
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Which client exposure is most likely to require postexposure prophylaxis for the nurse?
Which client exposure is most likely to require postexposure prophylaxis for the nurse?
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Which herb can enhance replication of HIV in clients?
Which herb can enhance replication of HIV in clients?
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What factor is most important to consider when determining initiation of antiretroviral therapy (ART) for a client with a CD4+ cell count of 400/µL?
What factor is most important to consider when determining initiation of antiretroviral therapy (ART) for a client with a CD4+ cell count of 400/µL?
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Which client would be appropriate for teaching about antiretroviral therapy (ART) in an HIV clinic?
Which client would be appropriate for teaching about antiretroviral therapy (ART) in an HIV clinic?
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When assessing an individual with early chronic HIV infection and a normal CD4+ count, which assessment should the nurse prioritize?
When assessing an individual with early chronic HIV infection and a normal CD4+ count, which assessment should the nurse prioritize?
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Which test does the Canadian Blood Services utilize to detect HIV genetic material in blood?
Which test does the Canadian Blood Services utilize to detect HIV genetic material in blood?
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What is the best way to reduce the risk of HIV infection from injectable drug use?
What is the best way to reduce the risk of HIV infection from injectable drug use?
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Which nursing action will be most helpful in assisting a young adult college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
Which nursing action will be most helpful in assisting a young adult college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
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Which of the following goals is most appropriate for a client with HIV infection who has developed Mycobacterium avium complex infection?
Which of the following goals is most appropriate for a client with HIV infection who has developed Mycobacterium avium complex infection?
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Which topic should the nurse include in the client teaching plan for a client with fat redistribution to the trunk after 7 years of HIV treatment?
Which topic should the nurse include in the client teaching plan for a client with fat redistribution to the trunk after 7 years of HIV treatment?
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Which medication is most important to administer at the right time for an HIV-positive client hospitalized with Pneumocystis jiroveci pneumonia?
Which medication is most important to administer at the right time for an HIV-positive client hospitalized with Pneumocystis jiroveci pneumonia?
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Which test is used to evaluate the effectiveness of antiretroviral therapy (ART)?
Which test is used to evaluate the effectiveness of antiretroviral therapy (ART)?
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Which information about an HIV-positive client is most important for the nurse to address when planning care?
Which information about an HIV-positive client is most important for the nurse to address when planning care?
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What is the priority nursing intervention for an HIV-infected client with a CD4+ cell count of 800 cells per microliter and an undetectable viral load ten years after seroconversion?
What is the priority nursing intervention for an HIV-infected client with a CD4+ cell count of 800 cells per microliter and an undetectable viral load ten years after seroconversion?
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How soon after delivery of the baby can ART treatment be started for a pregnant client diagnosed with HIV?
How soon after delivery of the baby can ART treatment be started for a pregnant client diagnosed with HIV?
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What is a priority information to include in a program to teach a community group about decreasing HIV infection incidence?
What is a priority information to include in a program to teach a community group about decreasing HIV infection incidence?
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What event is a client at an increased risk of developing after having an emergency splenectomy following an automobile accident?
What event is a client at an increased risk of developing after having an emergency splenectomy following an automobile accident?
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Which assessment should the nurse anticipate when noting numerous petechiae in a client?
Which assessment should the nurse anticipate when noting numerous petechiae in a client?
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Which laboratory result should be of most concern when reviewing data for an older-adult client?
Which laboratory result should be of most concern when reviewing data for an older-adult client?
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What action should the nurse implement following a bone marrow aspiration from the left posterior iliac crest on a client with pancytopenia?
What action should the nurse implement following a bone marrow aspiration from the left posterior iliac crest on a client with pancytopenia?
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Which assessment finding should the nurse anticipate in a client with chronic iron-deficiency anemia?
Which assessment finding should the nurse anticipate in a client with chronic iron-deficiency anemia?
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Study Notes
Immune Response and Transplantation
-
Types of Immunity:
- Innate immunity: present at birth, occurs without exposure to an antigen
- Natural active immunity: occurs when the body produces antibodies in response to an antigen, e.g., chickenpox
- Artificial immunity: induced by a vaccine or immune serum
- Cell-mediated immunity: involves T-lymphocytes, responsible for tumour immunity
-
Immune Deficiency Disorders:
- T-lymphocyte deficiency: increased risk of malignancy
- B-lymphocyte deficiency: impaired antibody production
- Combined immunodeficiency: impaired both cell-mediated and humoral immunity
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Allergic Reactions:
- Anaphylaxis: severe, life-threatening allergic reaction
- IgE: involved in anaphylactic reactions
- Atopic dermatitis: type 1 hypersensitivity disorder, associated with elevated IgE levels
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Transplantation:
- Graft-versus-host disease: occurs when donated T cells attack the client's tissues
- Immunosuppressant therapy: used to prevent rejection of transplanted organs
- Cyclosporine: nephrotoxicity is a major adverse effect
-
Plasmapheresis:
- Removes antibodies, antibody-antigen complexes, and complement from blood
- Used to treat systemic lupus erythematosus (SLE) and other autoimmune disorders
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Bone Marrow Transplant:
- Graft-versus-host disease: occurs when donated T cells attack the client's tissues
- Immunosuppressant therapy: used to prevent rejection of transplanted bone marrow
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Post-Transplant Care:
- Monitor for acute rejection
- Administer immunosuppressant medications
- Client education: importance of adhering to medication regimen and monitoring for signs of rejection### Angioedema and Allergic Reactions
- Angioedema is characterized by swelling of the eyelids, lips, and tongue.
- Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristics of other allergic reactions.
- To determine whether a client's angioedema has responded to prescribed therapies, the nurse should first check for swelling of the lips and tongue.
Kidney Transplant and Tissue Typing
- Positive crossmatching is an absolute contraindication to kidney transplantation, as it will lead to hyperacute rejection.
- The nurse should communicate the results of client-donor crossmatching to the healthcare provider.
Immunotherapy and Allergen Injection
- A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed.
- The nurse should communicate the size of the wheal at the site of the allergen injection to the healthcare provider.
Infection and HIV
- After an initial positive enzyme immunoassay (EIA) for HIV antibodies, the EIA is repeated before more specific testing such as the Western blot is done.
- The nurse should include information about the need for retesting to confirm the results when discussing the test results with the client.
- Development of Pneumocystis jiroveci pneumonia (PCP) meets the diagnostic criterion for AIDS.
- The nurse should anticipate a diagnosis of late chronic infection or AIDS in a client with PCP.
Nursing Care and HIV
- When a client is anxious and does not appear to hear what the nurse is saying, the nurse should first retest to confirm the results of the HIV test.
- The nurse should assess the client's psychosocial status before taking any other action when the client expresses concerns about dying.
- Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use antiretroviral therapy (ART) during pregnancy.
- The nurse should teach the client about the need to follow a stringent ART schedule to prevent drug resistance.
HIV and Herbs
- Some herbs, such as echinacea, should not be used by clients with HIV because they can enhance the replication of HIV.
HIV and Antiretroviral Therapy (ART)
- The nurse should consider the client's ability to comply with the ART schedule when determining whether to initiate therapy.
- Drug resistance develops quickly unless the client takes ART medications on a stringent schedule.
- The nurse should teach the client about the importance of taking ART medications as scheduled.
HIV and CD4+ Count
- Persistent generalized lymphadenopathy is common in the early stage of chronic HIV infection.
- The nurse should assess the client's lymph nodes when assessing an individual with early chronic HIV infection and a normal CD4+ count.
HIV and Blood Donation
- The Canadian Blood Services uses a nucleic acid amplification test (NAAT) to detect HIV genetic material in blood of potential donors.
Preventing HIV Infection
- Participation in needle and syringe exchange programs has been shown to control the rate of HIV infection.
- The nurse should inform the client that the best way to reduce the risk of HIV infection from drug use is to participate in a needle-exchange program.### HIV Infection and Care
- A client with a CD4+ cell count of 800 cells per microliter and an undetectable viral load is in the early chronic stage of HIV infection.
- At this stage, the body is able to produce enough CD4+ cells to maintain a normal CD4+ count.
- AIDS and opportunistic infections typically develop when the CD4+ count is much lower than normal.
- Priority nursing intervention at this stage is to encourage adequate nutrition, exercise, and sleep.
ART Treatment and Pregnancy
- Women infected with HIV should receive optimal ART immediately, regardless of pregnancy.
- ART treatment can be initiated while pregnant.
HIV Prevention and Education
- The most common way HIV is transmitted is through sexual contact.
- Education on preventing transmission between sexual partners is a priority.
- Other methods of transmission, such as perinatal transmission, needle sterilization, and blood transfusions, should also be addressed.
Prophylactic Measures for HIV Clients
- Vaccines recommended for HIV clients include hepatitis B, pneumococcal, and influenza.
- These vaccines are important for preventing other infections in HIV clients.
Hematological System
Splenectomy
- Splenectomy increases the risk of infection, especially with gram-positive bacteria.
- The risk of lymphedema, bleeding, and anemia is not increased after splenectomy.
Petechiae and Bleeding
- Petechiae are small, purplish-red lesions.
- Ecchymosis is bruising on the skin.
- Telangiectasia is small, focal red lesions.
- Purpura is a rash of purple, red, or brown spots on the skin or mucous membranes.
Laboratory Results
- A low WBC count indicates compromised immune function.
- A normal platelet count is around 400 ´ 109/L.
- A slight decrease in hemoglobin and hematocrit is not unusual in older clients.
Bone Marrow Aspiration
- A pressure dressing is used to cover the aspiration site after a bone marrow biopsy.
Anemia and Iron Deficiency
- Chronic iron deficiency anemia can cause loss of papillae on the tongue.
- Scleral jaundice is associated with hemolysis.
- Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
Polycythemia
- Polycythemia may cause visual abnormalities.
- A hemoglobin level of 200 g/L and a hematocrit of 54% indicate polycythemia.
Heparin and Coagulation
- aPTT testing is used to determine whether heparin is at a therapeutic level.
- FDP is useful in diagnosis of disseminated intravascular coagulation (DIC).
- PT and INR are used to test for therapeutic levels of warfarin.
Red Blood Cell Indices
- A low MCV indicates smaller-than-normal RBCs.
- Inadequate numbers of RBCs indicate anemia.
- Low levels of hemoglobin in RBCs result in a low MCH.
Lymph Nodes
- Enlarged and nontender nodes are most suggestive of malignancy.
- Firm nodes are an expected finding in an area of infection.
Hemorrhage and Hemoglobin
- Hemorrhage causes the release of more immature RBCs from the bone marrow into the circulation.
- The reticulocyte count is elevated after hemorrhage.
Neutropenia
- Neutropenic clients are at high risk for infection and sepsis.
- Monitoring temperature frequently is important in neutropenic clients.
Shift to the Left
- A shift to the left indicates that the number of immature polymorphonuclear neutrophils, or bands, is elevated.
- This is a sign of severe infection.
Ultrasound and Spleen
- The client is placed in a flat position before splenic ultrasound.
Pancytopenia and Bone Marrow Biopsy
- Bone marrow biopsy is a minor surgical procedure that requires a signed consent form.
Complete Blood Count
- An elevation in WBCs indicates that an abdominal infection may be the cause of the client's pain.
- Further diagnostic testing is needed in this case.
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Take this quiz to test your knowledge on Chapter 16 of Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition, covering topics such as immune response and transplantation.
