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NUR 236 unit 4
| Question | Answer |
|---|---|
| What is the most common way to detect allergies? | Scratch test (also called prick or puncture test). |
| How is immune globulin (Ig) given? | Through IV infusion. Stop after 10 minutes to check vitals and for reactions, then restart if stable. |
| Signs of Ig inflammation | Redness, warmth, swelling. |
| Signs of infection | Redness, warmth, swelling, and drainage. |
| If blood pressure drops and the patient has a reaction during an IV transfusion, what should you do? | Stop transfusion, call a code, give epinephrine, Benadryl, IV fluids, maintain airway, and provide oxygen. |
| A client with AIDS has a draining sarcoma lesion what is the nurse’s priority? | Dispose of soiled dressings properly in biohazard trash. |
| Chronic symptom of fibromyalgia? | Generalized musculoskeletal pain. |
| Primary lymphoid organs? | Bone marrow and thymus. |
| Secondary lymphoid organs? | Lymph nodes, spleen, tonsils, Peyer’s patches, appendix. |
| Best way for bedside nurses to prevent disease? | Standard precautions. |
| How is HIV acquired? | Sexual contact, mother-to-baby, or needle sharing |
| What should a nurse do if coworkers are gossiping about a patient with AIDS? | Report it to the charge nurse. |
| Who makes medical decisions if an AIDS patient designates a boyfriend as next of kin, but the mother objects? | The boyfriend (as chosen by the patient). |
| Main function of inflammation and immunity? | Protects the body from harmful organisms. |
| Elderly patient suspects infection but has normal temperature what should the nurse do? | Check for other specific signs of infection. |
| Purpose of the Gardasil vaccine? | Prevents HPV infection and reduces risk of cervical and testicular cancer. |
| Lab work used to monitor HIV immune status? | CD4 count and T-cell count. |
| Medication for HIV exposure prevention? | PrEP: Pre-exposure prophylaxis (Truvada + safe sex). PEP: Post-exposure prophylaxis (within 72 hours). |
| What diet is best for AIDS patients with mouth sores? | Soft mechanical diet; avoid hot or spicy foods. |
| What is an opportunistic infection? | Infection that occurs in people with weakened immune systems (e.g., AIDS → more susceptible to herpes). |
| Who is the best organ donor match? | An identical twin. |
| Best precaution if unsure about a patient’s HIV status? | Standard precautions. |
| What indicates improvement in a patient with wasting syndrome? | Weight gain. |
| Transmission routes for HIV? | Sexual contact, needles, mother-to-baby (including breast milk). |
| Proper handling of soiled dressings from HIV patients? | Double-bag, label as “biohazard,” and dispose properly. |
| If family argues about next of kin but another patient needs assistance, what should you do? | Call the social worker. |
| Two types of lupus? | Systemic lupus erythematosus (SLE) and discoid lupus (skin lupus). |
| Signs and symptoms of fibromyalgia? | Generalized musculoskeletal pain, fatigue, sleep problems, and tenderness. |
| What causes secondary lymphedema? | Parasites or lymphatic obstruction from trauma or surgery. |
| Who should receive the HPV vaccine and why? | Teenagers to prevent HPV, which causes cervical and testicular cancer. |
| What is the nursing priority during anaphylaxis? | Establish airway, give oxygen, epinephrine, antihistamine, and manage shock. |
| What are common opportunistic infections in AIDS? | Herpes, tuberculosis, Pneumocystis jiroveci, candidiasis. |
| Key lab indicator to begin ART (antiretroviral therapy)? | CD4 count <350 cells/mm³. |
| What are signs of systemic lupus erythematosus (SLE)? | Fatigue, joint pain, butterfly rash, hair loss, fever, and sun sensitivity. |
| Best nursing action for low-immunity patients? | Practice strict infection prevention and assess for early infection signs. |
| Define hypersensitivity reaction. | Excessive immune response to a normally harmless substance (e.g., allergy). |
| What is hyperalgesia? | Heightened pain response in fibromyalgia. |
| What is allodynia? | Pain response to normally non-painful stimuli. |
| What test checks for dormant infectious diseases like TB? | Mantoux (tuberculin skin) test. |
| What are the protective mechanisms of the immune system? | Inflammatory response and immune response. |
| What is innate immunity? | Natural defense you’re born with. |
| What is acquired immunity? | Developed after exposure to germ or immunization. |
| ABX | Antibiotics |
| BX | Biopsy |
| TX | Treatment |
| DX | Diagnosis |
| HX | History |
| SX | Symptoms |
| RX | Prescription |
| PX | Prognosis |
| FX | Fracture |
| CX | Culture |
| VS | Vital Signs |
| What are the main organs and structures of the immune system? | Bone marrow thymus gland lymph nodes spleen tonsils Peyer’s patches appendix lymphatic vessels. |
| What is the function of the bone marrow? | Produces and matures blood cells, including lymphocytes (B cells). |
| What is the function of the thymus gland? | Develops and matures T lymphocytes (T cells). |
| What happens to the thymus gland after adolescence? | It shrinks in size and produces fewer T cells. |
| What is the function of the lymph nodes? | Filter lymph fluid and trap pathogens, producing lymphocytes and antibodies. |
| What is the function of the spleen? | Filters blood, removes old or damaged red blood cells, and helps activate lymphocytes. |
| What is the function of the tonsils? | Protect the body from infections entering through the mouth and throat. |
| What is the function of Peyer’s patches? | Located in the small intestine — monitor and defend against pathogens in the digestive tract. |
| What is the function of the appendix? | serving as a "safe house" for beneficial gut bacteria and containing lymphoid tissue that supports the immune system |
| What is the function of lymphatic vessels? | Transport lymph fluid and immune cells throughout the body, maintaining fluid balance. |
| What is lymph fluid? | Clear fluid that carries white blood cells, nutrients, and waste between tissues and bloodstream. |
| What are the primary lymphoid organs? | Bone marrow and thymus gland (where lymphocytes are produced and matured). |
| What are the secondary lymphoid organs? | Lymph nodes, spleen, tonsils, Peyer’s patches, and appendix (where immune responses occur). |
| What are the two main types of immunity? | Innate and acquired |
| What are examples of innate immune defenses? | Skin, mucous membranes, cilia, stomach acid, inflammatory response, fever, and phagocytosis. |
| What is passive immunity? | Temporary immunity that occurs when antibodies are transferred from another source. |
| What is active immunity? | When the body produces its own antibodies after exposure to an antigen. |
| Humoral immunity | B cells produce antibodies that circulate in body |
| Cellular immunity | T cells attack infected or abnormal cells directly. |
| What is the main cause of acquired immune deficiency? | HIV infection. |
| What treatments are used for immune deficiencies? | Immune globulin therapy, bone marrow transplant, colony-stimulating factors (e.g., filgrastim), and antimicrobials. |
| What are signs of early HIV infection? | Flu-like symptoms, swollen glands, oral thrush, night sweats, and weight loss. |
| What are the three stages of HIV infection? | Acute (flu-like, high viral load) Chronic (asymptomatic but contagious) AIDS (terminal, severe immune damage). |
| How is lupus diagnosed? | Must have 4 of 11 clinical/lab findings (no single definitive test). |
| What is primary lymphedema? | Congenital (inherited) lymphatic deficiency, often in lower extremities. |
| What is fibromyalgia? | Chronic pain syndrome with widespread musculoskeletal pain and tenderness. |
| Post-Exposure Prophylaxis PEP | medication started within 72 hours after possible exposure to HIV. |
| What is a pathpgen | Any microorganism that causes disease in the body |
| What are the sores or lumps that can develop in patients with AIDS due to a virus? | Kaposi sarcoma |
| The student demonstrates understanding of passive natural immunity when they make which statement? | Breastfeeding is the best way to enhance the infant’s immunity |
| The first protective line of defense the body has against pathogens is | The skin |
| During a health promotion outreach for older adults, which statement is true regarding infection risk? | Decreased cilia in the lungs provide a more hospitable environment to harmful organisms. |
| A patient asks, “What does autoimmune disease mean?” The best response is | Immune defenses are attacking the normal body cells |
| Which sign or symptom indicates the presence of infection in a sacral pressure ulcer? | Purulent drainage. |
| While caring for an immunocompromised patient, which action indicates a need for supervision? | Allowing family and visitors to come and go as needed. |
| During data collection, a patient says, “I take garlic pills to reduce my risk for cancer.” The appropriate nursing response is | How much and how often do you take your garlic pills? |
| Your patient receives a flu shot and a pneumonia vaccine before discharge. What type of immunity do these provide? | Artificially acquired active immunity |
| Before receiving antivenin, the patient asks, “Why am I getting this?” The correct response is | The antivenin must be given as early as possible to afford immediate reversal of the effects of the venom. |
| You explain the health care provider’s order to draw blood for HIV genotyping. The patient asks, “How does that help in my treatment?” What is the best explanation for the test? | Determines the presence of any mutations in the virus |
| A patient known to be positive for HIV is admitted with oral thrush, recurrent vaginal yeast infections, and skin infections. What do these signs indicate? | Opportunistic infection |
| Priorities for developing an HIV care plan (Order of priority) | 1. Clinical data → 3. Medication tolerance → 2. Compliance with therapy → 4. Support system → 5. Patient expectations |
| A nurse is reviewing medication orders for a female patient with SLE who is positive for the presence of antiphospholipid antibodies. You would seek clarification from the health care provider about which type of medication? | Oral contraceptives |
| A patient has the medical diagnosis of fibromyalgia. Which nursing problem is the highest priority on this patient’s care plan? | Chronic pain |
| You admit an older adult man with NHL. On initial assessment, you note that the patient is slightly confused, is irritable, is emaciated, has poor dentition, and is homeless. What is the priority nursing problem? | Potential for infection |
| Systemic autoimmune diseases (Select all that apply) | Rheumatoid arthritis, Systemic lupus erythematosus, and Goodpasture syndrome |
| primary lymphedema SS | Swelling, heaviness and fullness, pitting edema, skin changes, aching or pain, reduced range of motion, recurrent infections |
| secondary lymphedema SS | Swelling, Heaviness or fullness, skin changes, restricted movement, Aching, tingling, or numbness, Difficulty with clothing |
| The student nurse learns the most important function of inflammation and immunity is? | Provides protection against the organisms getting in |
Created by:
kaimcd