The patient in early labor says to the nurse: “I will pass on protection from diseases and the baby will not ever need any shots.” The best response by the nurse should be:
C. Babies acquire antibodies from their mother which lasts only a few months.
The school nurse starts a clean-up campaign at a local elementary school in an effort to combat some of the allergens that cause one of the most common allergic response disorders, which is:
B. Fungi are principal allergens which can trigger respiratory allergic responses such as asthma.
The nurse is discussing the body’s first and second lines of defense against infection with a community group. The first line of defense includes which of the following?
A. The sweat glands excrete an antimicrobial enzyme.
The nurse explains that medication being given to a client with a severe inflammatory response mimics a hormone secreted by the adrenal cortex. This hormone is:
C. Cortisol slows the release of antihistamine and stabilizes lysosomal membranes.
The nurse explains that with the exposure to an antigen, the initiator of the inflammatory response is the presence of histamine, which is released by the:
B. Basophil release histamine.
The nurse is bathing an immunodeficient patient who is suffering from Cryptococcus infestation. The organism is classified as a:
B. Cryptococcus fungal infections can be life threatening.
When a mosquito or a fly carries an organism that infects another living organism, this mode of transmission is infection via:
A. Vector-borne diseases are carried from one host to another. Part of the life cycle of the pathogen occurs in the body of the fly, mosquito, or tick.
The home health nurse is teaching the family that the most effective method to control the spread of communicable disease is which of the following?
D. Good hand washing is the cornerstone of infection control.
The home health nurse recommends air conditioner duct cleaning as a precaution against diseases caused by:
B. Air blowing into a room may be the mode of transfer of fungi spores, which have remained dormant in the duct during nonuse.
The school nurse cautions a group of parents about children playing barefoot on dirt that may lead them to be exposed to infections caused by:
B. Worms in the dirt seek entry through the foot skin and into the blood circulation, where they are carried to the lungs, coughed up into the mouth, and swallowed into the GI tract, where they cause serious infections. Barefooted children who do not have proper hygiene are at risk for these worm infections.
The large, heavy, and older adult patient, post stroke, develops an infected decubitus on the sacrum during the hospital stay. When the patient goes home, about 2 weeks later, the patient returns to the hospital with pneumonia. The distinction between these two infections is which of the following?
D. Because the decubitus developed during the stay in a health care facility, it is classified as nosocomial. Because the patient did not have pneumonia when he left the facility, it is classified as community-acquired.
The home health nurse, on a visit to administer the fifth in a series of 10 antibiotic doses, is told that the patient is now complaining about a bothersome vaginal discharge. The nurse will communicate the problem to arrange for medication and teaches the patient that this condition is probably the result of:
B. Antibiotics frequently wipe out “good” bacteria and cause other bacteria to overgrow, causing the vaginitis.
The nurse assesses that the patient who has acquired a nosocomial infection is most likely the patient with:
C. Iatrogenic or nosocomial infections are those acquired during the hospital stay. Urinary catheters are frequently the source of such infections. Abscesses frequently follow a ruptured appendix; lice and athlete’s foot are long-term conditions not caused by hospital interventions.
A community picnic is held. Following this, a number of the attendees become ill. The pathogen in this case was acquired via:
C. Food at the picnic that was shared in common became the vehicle for transmission.
The nurse caring for an immunosuppressed patient is diligent about protecting the patient from infection. When visitors come in, in addition to having them put on isolation garb, the nurse would prohibit them bringing:
C. The soil in the flower pot is a reservoir for bacteria and fungi.
The parent asks the nurse to explain which type of drugs will not be used in the medical treatment of their child’s allergic reaction to bee stings.
A. The immune response is dampened by corticosteroids.
A patient has had several increasingly severe allergic reactions during last year’s pollen season. This year, the patient comes regularly to the office to receive some antigen injections. The nurse teaches that these will:
D. Injections of increasing amounts of minute doses of the antigen will desensitize the body against the antigen.
A patient who is receiving daily steroids for control of a condition calls the nurse to ask advice about whether a small child who has been exposed to influenza should come and visit because she has not had any symptoms. An appropriate response by the office nurse would be:
D. Children, especially those who have been exposed to a contagious disease but are not yet symptomatic, are still very contagious, especially to the immunocompromised patient.
The patient with the diagnosis of Clostridium difficile infection asks what has caused the diarrhea. The nurse responds that it is caused by:
A. Superinfections such as Clostridium difficile are caused by long-term antibiotic therapy, which kills all the natural flora of the bowel and causes diarrhea.
The patient receiving a large IM dose of antibiotic was asked to please wait 20 to 30 minutes before checking out. The reason for this request is that:
B. Antibiotic administration is a common cause of anaphylaxis. The patient is asked to wait so that if this condition occurs, the patient will be with medical personnel to reverse it.
After receiving an injection of penicillin, the patient undergoes an anaphylactic reaction. The nurse should immediately:
B. The first intervention should be to supply oxygen. Notification of the charge nurse and the administration of fluids to combat hypovolemia will come afterward. Covering with blankets would increase the vasodilation and increase the shock.
The Centers for Disease Control and Prevention (CDC) has issued new guidelines for infection control. Nursing care plans for patients with infection mainly address which protocol?
A. The CDC has issued new guidelines for Standard Precautions for infection control. These cover a, b, and d. Only answer c is all-inclusive.
The nurse is aware that wound healing can be enhanced with the administration of vitamin:
D. The addition of vitamin C and Zinc to the medication regimen can hasten wound healing.
The patient is hospitalized with cryptococcal pneumonia and AIDS. The nurse knows that the Standard Precautions for this patient will include the most important precaution. Which of the following is correct?
D. Hand washing before and between care in areas of contamination is necessary.
The organs involved in immunity include the tonsils, spleen, lymph nodes, and:
B. The liver filters the blood and plays a part in the immune response by the production of globulins and other chemicals involved in the immune response.
The nurse explains that the difference between medical asepsis and surgical asepsis is that medical asepsis requires:
A. Surgical asepsis is sterile technique. Medical asepsis is considered a clean technique.
The school nurse is required to report to the health department all cases of (select all that apply):
Rubella, Lyme disease, and salmonella are all reportable. Lice and Clostridium difficile are not reportable.
The nurse assesses a high eosinophil count in a pediatric patient. The nurse recognizes that this elevation is an indicator of ____________________.
Allergy
Persons with HIV have fallen victim to PCP, Pneumocystis jiroveci, a serious pulmonary infection caused by a ____________________.
Fungus
The nurse reminds the patient who is to undergo hyperbaric oxygen therapy that the clothing worn into the chamber must be made of ____________________.
Cotton
Prioritize the events of an antibody-mediated immunity response.
1. Antibodies seek out and bind with specific antigen.
2. Antigen binds to a B lymphocyte.
3. Circulating antibody-antigen complexes are destroyed.
4. Antibodies are produced.
5. Antibodies are replenished.
2, 4, 1, 3, 5
Antigen binds to a B lymphocyte and antibodies are produced for that specific antigen. Antibodies seek out and bind with the specific antigen when it is reintroduced to the organism and bind with them. These circulating antigen-antibody complexes are targeted and destroyed by phagocytes. Antibodies are continually replenished in most cases.
