Question 1

A patient tells the nurse that he had a tuberculin test several months ago,and the site of injection became very red and inflamed.How should the nurse interpret this information?

Accepted Answer

The redness and inflammation at the site of injection are indicative of a type IV hypersensitivity response, which is a positive reaction to the tuberculin test.

Question 2

The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections.What should be included in these instructions?

Accepted Answer

C

Question 3

A patient with leukemia begins to have seizures.The nurse realizes that the onset of seizure activity is most likely associated with which occurrence?

Accepted Answer

Seizure activity in a patient with leukemia is most likely associated with malignant cells infiltrating the central nervous system. Leukemia is a cancer of the blood cells, and as the malignant cells proliferate and spread, they can invade different organs and tissues throughout the body, including the brain and spinal cord. This infiltration can disrupt normal neurological function and lead to seizures. Hemodynamic instability, pancytopenia, and expansion of malignant cells may be complications of leukemia, but they are not directly related to seizure activity.

Question 4

A patient,recovering from skin grafts to the arm because of burn injuries,is demonstrating an increase of drainage,bleeding,and edema.The nurse prepares to treat which complication?

Accepted Answer

The answer of A patient,recovering from skin grafts to the...

Question 5

The nurse is assessing a patient for altered immunocompetence.Which findings would indicate that the patient is at risk for developing an immunocompetence-associated illness? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Slow wound healing and easy bruising (A) as well as mouth sores and oral patches (E) are indicative of altered immunocompetence. These symptoms suggest the body's immune system is not functioning properly, making the patient more susceptible to infections and illnesses. Bursitis and muscle cramps (B), heart palpitations (C), and heartburn and increased flatus (D) are not directly related to immunocompetence.

Question 6

A patient infected with HIV is being monitored for the development of AIDS.Which characteristics would the nurse monitor? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

The CD4+ T-cell count is a marker of immune function in HIV-infected individuals and is used to determine the progression to AIDS. The presence of Pneumocystis jiroveci (PJP) infection and cytomegalovirus (CMV) are opportunistic infections that commonly occur in individuals with AIDS. Recurrent E.coli urinary tract infection is not a specific characteristic of AIDS and may occur in individuals without HIV infection. White blood count is not a specific marker for the progression of HIV to AIDS.

Question 7

An older adult patient admitted with malnutrition begins to demonstrate signs of pneumonia.The nurse would explain which possible etiology of this pneumonia?

Accepted Answer

Malnutrition can lead to a weakened immune system, making the patient more susceptible to infections such as pneumonia.

Question 8

A patient with an autoimmune disorder says,"I don't know why this happened to me.I try to exercise and eat well." How should the nurse respond?

Accepted Answer

Choice B accurately explains the cause of autoimmune disorders, which is when the immune system mistakenly attacks the body's own cells. Choices A and D are incorrect, as there is not necessarily a direct link between autoimmune disorders and vitamin deficiencies or chronic illnesses. Choice C is partially correct in that repeated exposure to certain factors may trigger an autoimmune response, but it does not fully explain the complex nature of autoimmune disorders.

Question 9

A patient tells the nurse that it seems like the only time she gets a cold is when she is under higher than normal stress.What information should the nurse provide?

Accepted Answer

Stress increases cortisol levels, which can suppress the immune system, making the body more susceptible to infections like the common cold.

Question 10

A patient with acute myelogenous leukemia is scheduled for a hematopoietic stem-cell transplant (HSCT).How would the nurse categorize this patient's treatment goal?

Accepted Answer

The goal of HSCT is to effect a cure for the patient's leukemia.

Question 11

A patient hospitalized for treatment of a mediastinal malignancy is at risk for developing superior vena cava (SVC)syndrome.The nurse would monitor for the development of which signs of this disorder? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Superior vena cava (SVC) syndrome occurs when the SVC is compressed or obstructed by tumor growth or by thrombosis, leading to impaired blood flow from the head, neck, and upper extremities back to the heart. This results in increased venous pressure and subsequent symptoms such as headache (due to increased intracranial pressure), distended neck veins, and flushed face (both due to increased venous pressure in the upper body). Decreased pedal pulses and pain in the lower back are not directly related to SVC syndrome, as this condition primarily affects the upper body.

Question 12

A patient is prescribed filgrastim (Neupogen).Which nursing intervention is indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Filgrastim should be allowed to warm to room temperature before administration, but not for more than 6 hours. It should be administered at least 24 hours after chemotherapy to avoid interference with the effects of the chemotherapy.

Question 13

The blood sample from a patient's bone marrow biopsy included Auer rods.The nurse would prepare to provide care for which disorder?

Accepted Answer

Auer rods are often seen in patients with acute myelogenous leukemia, a type of cancer that affects myeloid cells in the bone marrow. Auer rods are abnormal rod-shaped structures that are found inside the white blood cells known as myeloblasts, which are typically seen in the bone marrow or in the circulating blood of patients with this type of leukemia.

Question 14

A female patient is concerned after learning that a person with whom she had a casual sexual encounter has been diagnosed as being HIV positive.Which other patient statement would the nurse evaluate as significant?

Accepted Answer

The statement "I did have a cold and sore throat last week, but it has cleared up without problems" is significant because it could potentially be an early symptom of HIV infection. The absence of symptoms (A), number of sexual encounters (B), and menstrual history (D) are not as relevant when evaluating possible HIV exposure.

Question 15

A patient being treated with isoniazid for tuberculosis develops symptoms of systemic lupus erythematosus (SLE).The patient says,"I can't believe that I am so sick.First I get TB and now this.What is going to happen to me?" What nursing response is indicated?

Accepted Answer

Isoniazid is known to trigger symptoms of SLE in some patients. Changing the medication can often relieve the symptoms of SLE, while continuing the TB treatment. Therefore, the nurse should provide reassurance in this case that often SLE symptoms go away after the TB medication is changed. Option A is not appropriate as it does not provide any concrete information or reassurance. Option B is incorrect as the treatment of SLE is not dependent on the TB cure. Option D is not supported by facts and can increase anxiety in the patient.

Question 16

A 55-year-old patient tells the nurse that he seems to be getting "more colds" as he gets older.Which possible explanation would the nurse have for this observation?

Accepted Answer

The thymus gland shrinks with aging,reducing the maturation and differentiation of T cells needed to fight infections. This results in a weakened immune response to infections, making the individual more susceptible to infections such as colds.

Question 17

A patient with neutropenia develops a fever.Which nursing action is most important?

Accepted Answer

When a patient with neutropenia develops a fever, it is a medical emergency and requires immediate attention. Discussing the finding with the primary care provider is the most important nursing action to take so that prompt treatment can be initiated.

Question 18

A patient receiving a blood transfusion reports nausea and back pain 10 minutes into the transfusion.The nurse realizes the patient is experiencing which type of hypersensitivity response?

Accepted Answer

The symptoms described are indicative of a Type II hypersensitivity reaction, which occurs when the immune system targets cells that have foreign antigens bound to their surface, such as in the case of a mismatched blood transfusion.

Question 19

A patient in the acute care unit has developed neutropenia.A nurse would identify which history as a possible etiology of this condition?

Accepted Answer

Neutropenia is a decrease in the number of neutrophils, a type of white blood cell that helps the body fight off infections. Chemotherapy treatment can cause neutropenia because it can damage the bone marrow, where neutrophils are produced. A bacterial infection, vitamin C deficiency, or blood sugar level would not typically be the primary cause of neutropenia.

Question 20

A patient receiving treatment for lymphoma suddenly becomes critically ill and is diagnosed with tumor lysis syndrome.The nurse would review laboratory results for which expected levels? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Tumor lysis syndrome is characterized by the rapid release of intracellular components into the blood following the lysis of tumor cells. This leads to high serum phosphate (due to the release of phosphate from cells), low serum calcium (as calcium binds to the excess phosphate, reducing its serum levels), and high uric acid (from the breakdown of nucleic acids). Potassium levels are typically high, not low, due to the release from intracellular stores, and sodium levels may not be directly affected, making hyponatremia not a typical feature.

Quiz 30: Alterations in White Blood Cell Function and Oncologic Emergencies