A
A parent tells the nurse their child receiving leukemia chemotherapy has been exposed to varicella (chickenpox). Which instruction should the nurse provide the parent?
1. If the child develops chicken pox come into the clinic for an injection of varicella immune globulin.
2. Bring the child into the clinic as soon as possible to receive an injection of varicella immune globulin.
3. Bring the child to the clinic immediately to receive a vaccination for chickenpox.
4. Keep the child away from other children to avoid further exposure to varicella.
Answer: 2
Explanation:
1. Immune globulin is not administered after the disease develops.
2. Immune globulin must be given before the disease develops.
3. The child is immunosuppressed; administering a vaccination for chickenpox may result in developing the disease.
4. Keeping the child away from others will not prevent the disease from developing because the child has already been exposed to it.
Which is a nursing priority to include in the teaching for the client prescribed an immunosuppressant?
1. Obtain adequate exercise.
2. Drink plenty of fluids.
3. Eat plenty of fruits and vegetables.
4. Avoid large crowds.
Answer: 4
Explanation:
1. An immunosuppressant places the client at risk for infection. Adequate exercise is important but will not prevent infection.
2. An immunosuppressant places the client at risk for infection. Drinking plenty of fluids is important but will not prevent infection.
3. An immunosuppressant places the client at risk for infection. Eating plenty of fruits and vegetables is important but will not prevent infection
4. An immunosuppressant places the client at risk for infection. The client should be instructed to avoid large crowds.
Which information should the nurse include in the discussion with a client about humoral and cell-mediated immune responses?
1. Helper T cells are an important part of humoral immunity.
2. Humoral immunity refers to immune responses where targets are attacked by immune cells.
3. B lymphocytes are an important part of cell-mediated immunity.
4. Humoral immunity refers to immune responses that are mediated by antibodies
Answer: 4
Explanation:
1. Helper T cells are part of cell-mediated immunity, not humoral immunity.
2. Humoral immunity refers to immune responses that are mediated by antibodies.
3. B lymphocytes are part of humoral immunity, not cell-mediated immunity.
4. Humoral immunity refers to immune responses that are mediated by antibodies.
Which describes the major difference between B cell lymphocytes and T cell lymphocytes?
1. T cells produce clones.
2. B cells produce antibodies.
3. T cells produce antibodies.
4. B cells produce clones.
Answer: 2
Explanation:
1. B and T cells both produce clones.
2. B cells produce antibodies.
3. T cells do not produce antibodies but rather cytokines.
4. B and T cells both produce clones.
A parent asks the nurse when their infant will receive the hepatitis A vaccine. Which information should the nurse provide?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
1. "The first dose will be administered before you take your baby home from the newborn nursery."
2. "It will be included in the series of immunizations given at 2 months, 4 months, and 6 months."
3. "Your child will receive the first dose at 12 months."
4. "Not until school age."
5. "About 6 to 12 months after the initial vaccine, a booster will be given."
Answer: 3, 5
Explanation:
1. Hepatitis A is not given to a newborn.
2. Hepatitis A is not given with this series.
3. The first dose of hepatitis vaccine is administered when the child is 12 months old.
4. The hepatitis A vaccine is administered to children at an earlier date than school age.
5. A booster immunization is given 6-12 months after the initial immunization
The nurse is preparing to administer a second dose of diphtheria-pertussis-tetanus (DPT) when the parent expresses concern that their child developed a red rash after the previous diphtheria-pertussis-tetanus (DPT) immunization. Which action should the nurse take?
1. Administer only a pertussis-tetanus immunization.
2. Withhold this immunization and contact the healthcare provider.
3. Instruct the parent to give the child acetaminophen (Tylenol) if another rash develops.
4. Administer diphenhydramine (Benadryl) prior to the diphtheria-pertussis-tetanus (DPT) immunization.
Answer: 2
Explanation:
1. Pertussis-tetanus is not an immunization.
2. This red rash is unexpected and could indicate a potential adverse reaction to the vaccine such as anaphylaxis, therefore, the nurse will withhold the immunization and contact the healthcare provider.
3. Administering acetaminophen (Tylenol) does not address the problem of potential anaphylaxis.
4. Administering diphenhydramine (Benadryl) does not address the problem of potential anaphylaxis.
A parent expressed concern to the nurse that their child does not have adequate immunity to chicken pox. Which response should the nurse provide?
1. "As long as your child has received all of their vaccinations, they should have adequate immunity."
2. "If you are concerned, we can administer a booster."
3. "It is unpredictable as to who will develop chicken pox."
4. "A titer can be drawn to determine if there is adequate immunity."
Answer: 4
Explanation:
1. Telling a parent that because their child received all of the vaccines and will have adequate immunity is incorrect information.
2. Administering a booster without evaluating a titer is not appropriate.
3. A titer will help determine if the child has an adequate amount of antibody to protect them against contracting chicken pox.
4. A titer will help determine if the child has an adequate amount of antibody to protect them against contracting chicken pox.
The nurse has provided education for a client post-transplant surgery that is prescribed immunosuppressant drugs. Which statements made by the client indicate an understanding of the information?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
1. "I will report hair loss to my healthcare provider."
2. "I will wear a protective mask when going out in public."
3. "I will avoid exposure to individuals who have infections."
4. "I will make sure I use reliable contraception."
5. "I will avoid eating raw fruits and vegetables."
Answer: 1, 3, 4, 5
Explanation:
1. Hair loss may indicate significant immunosuppression and should be reported.
2. It is not necessary to wear a mask in public.
3. Avoiding exposure to individuals who have infections is a necessary precaution when a client takes immunosuppressant drugs.
4. Practicing reliable contraception is a necessary precaution when a client takes immunosuppressant drugs.
5. The client should avoid raw fruits and vegetables that can harbor infection
Which is produced by T cells?
1. Cytokines
2. Leukotrienes
3. Lymphocytes
4. Erythrocytes
Answer: 1
Explanation:
1. Cytokines are produced by T cells to kill off foreign organisms.
2. Leukotrienes are not produced by T cells.
3. Lymphocytes are blood products that assist with the immune system.
4. Erythrocytes are red blood cell components.
A parent tells the nurse, "I am breastfeeding, so my baby is receiving my immunity. I do not see why any other vaccinations are necessary." Which responses should the nurse include in the discussion?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
1. "You are correct that your baby will receive some passive immunity from you."
2. "The immunity your baby is receiving only lasts while you are breastfeeding."
3. "There are some diseases for which immunity is not passed from mother to child."
4. "Your baby will need the extra protection provided by standard immunizations."
5. "Vaccines are not indicated until you completely stop breastfeeding."
Answer: 1, 3, 4
Explanation:
1. The mother is correct that passive immunity to some diseases is provided through the placenta and through breast milk.
2. The passive immunity the infant receives has a fast onset but only lasts 3 to 6 months.
3. The passive immunity the infant has received does not protect them from the diseases that acquired immunity does.
4. In order to be protected from many diseases, the child will need acquired immunity from vaccine.
5. The vaccine schedule for a breastfed infant is the same as for an infant who is not breastfed.
The nurse has provided parental education on infant immunization. Which statements made by the parent indicate an understanding of the information?
Note: Credit will be given only if all correct choices and no incorrect choices are selected Select all that apply.
1. "The immunizations are more effective if they are given closer together."
2. "The baby might have a mild fever and be fussy for a few days."
3. "I will call the healthcare provider immediately if the baby develops a fever."
4. "I can give acetaminophen (Tylenol) if the baby has a mild fever."
5. "I should be concerned that a mild fever may indicate an allergic reaction has occurred."
Answer: 2, 4
Explanation:
1. The recommended immunization schedule should be followed. There is no benefit to administering immunizations closer together.
2. A mild fever is a typical reaction to immunizations.
3. The healthcare provider should be notified if the fever is high.
4. Acetaminophen (Tylenol) is indicted for relief of mild symptoms.
5. A mild fever does not indicate there is an allergic reaction to the immunization.
A parent tells the nurse they do not want their child vaccinated because there are too many risks associated with the vaccines. Which response should the nurse provide the parent?
1. "Vaccinations are safe so there is no reason to worry."
2. "Vaccinations have some risks, but the benefits outweigh the risks."
3. "The community has been misinformed about the use of vaccines."
4. "Vaccinations will be required for your child to attend school."
Answer: 2
Explanation:
1. Telling a parent not to worry about the effects of vaccines does not address their concern.
2. While there are some risks to vaccines, there are many more deaths and serious illnesses that occur from the diseases than from the vaccinations.
3. Telling the parent that the community has been misinformed is not a statement that fosters therapeutic communication.
4. A parent has the right to decline having their child vaccinated.
Which information should the nurse include when providing education for an adult female client that is beginning the series of hepatitis B immunizations?
1. "Contact your healthcare provider if you develop pain at the injection site, mild fever, or soreness."
2. "Practice reliable birth control for 3 months after the administration of the vaccinations."
3. "Immediately report any signs of bleeding such as hematuria, or bleeding from the gums."
4. "Avoid crowded areas where you might be exposed to an infectious disease."
Answer: 2
Explanation:
1. It is not necessary to contact the physician if pain develops at the injection site or if the client develops a mild fever or soreness. These are expected effects.
2. The client should practice reliable birth control for 3 months after the administration of the vaccines to prevent harm to a developing fetus.
3. Bleeding is not associated with hepatitis B immunizations.
4. It is not necessary to avoid crowded areas following a hepatitis B immunization.
Which is a priority assessment when planning care for a client receiving immunostimulant therapy?
1. Changes in weight
2. Intake and output
3. Hepatic enzymes
4. Vital signs
Answer: 3
Explanation:
1. Weight changes are not the highest priority.
2. Monitoring intake and output is important but not the most important consideration.
3. Immunostimulants are hepatotoxic when used long term. Hepatic enzymes may become elevated, which could require discontinuation of the drug.
4. Vital signs are necessary with any medication.
A client tells the nurse they have been treated with interferon alfa-2b for cancer. Which types of cancer should the nurse recognize the client may have been treated for?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
1. Breast cancer
2. Malignant melanoma
3. Kaposi's sarcoma
4. Bladder cancer
5. Oral cancer
Answer: 2, 3, 4
Explanation:
1. Breast cancer is not treated with interferon alfa-2b.
2. Malignant melanoma is one of the cancers treated with interferon alfa-2b.
3. Kaposi's sarcoma is one of the cancers treated with interferon alfa-2b.
4. An off-label use of interferon alfa-2b is the treatment of bladder cancer.
5. There is no indication for use of interferon alfa-2b in treatment of cancers located in the sinuses.
A client receiving interferon alfa-2b (Intron-A) tells the nurse that they get very sleepy and thirsty every time they take the prescription. Which assessment question should the nurse ask the client?
1. "Are you consuming at least eight glasses of water daily?"
2. "Are you including beverages with alcohol in your diet?"
3. "Have you had any flu symptoms lately?"
4. "How much time have you spent out in the sun?"
Answer: 2
Explanation:
1. There is no indication to drink eight glasses of water daily when taking immunostimulants.
2. Combining immunostimulants with ethanol can result in excessive drowsiness and dehydration.
3. While flu-like symptoms are common with immunostimulants, this question does not address the client's concerns.
4. Exposure to the sun exposure is not associated with the client's symptoms.
The nurse has provided the education for a client prescribed cyclosporine (Neoral). Which statement made by the client indicates an understanding of the information?
1. "I should not have grapefruit."
2. "I will check my blood pressure as it may run low."
3. "I should take my prescription at mealtimes."
4. "I may experience an increased urine output."
Answer: 1
Explanation:
1. Grapefruit increases blood levels of cyclosporine and should not be consumed by the client while taking cyclosporine.
2. Cyclosporine can cause hypertension.
3. Food decreases the absorption of cyclosporine.
4. Cyclosporine can decrease urine output.
Which question by a client receiving interferon alfa-2b (Intron-A) indicates further assessment is necessary?
1. "I really feel sad; do I need to see a psychiatrist?"
2. "Is it safe to drink grapefruit juice with this medication?"
3. "Do I need to limit my fluids while on this medication?"
4. "Is it okay to use aspirin or ibuprofen products while on this medication?"
Answer: 1
Explanation:
1. Use of immunostimulant drugs can lead to the development of encephalopathy. The client's mental status should be assessed and the client monitored for signs and symptoms of depression and suicidal ideation.
2. There is no relationship between interferon alfa-2b and grapefruit juice.
3. There is no relationship between limiting fluids and interferon alfa-2b.
4. There is no relationship between interferon alfa-2b and aspirin or ibuprofen products.
Which are included in the class of immunosuppressants?
1. Gamma globulin
2. Glucocorticoids
3. Antipsychotics
4. Antifungals
Answer: 2
Explanation:
1. Gamma globulin is not a class of immunosuppressants.
2. Glucocorticoids are a class of immunosuppressants.
3. Antipsychotics are not a class of immunosuppressants.
4. Antifungals are not a class of immunosuppressants.
Which information should the nurse include in the education for influenza vaccinations?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
1. The influenza vaccine is administered as an injection.
2. Children should not receive influenza immunizations until age 10.
3. Intranasal vaccine is available for preschool children.
4. Many adults have a choice between injectable and intranasal forms of immunization.
5. A child will receive one dose at 6 months and then every year.
Answer: 4, 5
Explanation:
1. An injection is not the only form used to administer the influenza vaccine.
2. Influenza immunizations are started earlier than age 10.
3. There is not an intranasal vaccine for preschool children.
4. An intranasal influenza vaccine is available for many adults.
5. A child will receive one dose at 6 months and then every year.
Which is the nurse's priority assessment for a client prescribed cyclosporine (Sandimmune)?
1. Infection
2. Peripheral edema
3. Headaches
4. Cardiac output
Answer: 1
Explanation:
1. It is important to monitor for infection as cyclosporine is an immunosuppressant.
2. Cyclosporine may result in decreased urine output, but this is not the priority concern.
3. Cyclosporine may cause headaches, but this is not the priority concern.
4. Hypertension may result from use of cyclosporine, but there is no direct relation to cardiac output.
Which information should the nurse include when discussing the body's defense against an invading organism?
1. Nonspecific body defense is effective primarily against bacteria.
2. Specific body defense usually only acts against a single organism.
3. Specific body defense includes the complement system.
4. Nonspecific body defense is also known as the immune response.
Answer: 2
Explanation:
1. Nonspecific body defense is effective against many kinds of microbes and environmental hazards, not just bacteria.
2. Specific body defense usually only acts against a single organism.
3. Nonspecific body defense includes the complement system.
4. Specific body defense is known as the immune response.
Which of the following should the nurse identify as a component of the specific immune response?
1. Lymphocytes
2. Phagocytes
3. Epithelial lining of the skin
4. Gastrointestinal membrane
Answer: 1
Explanation:
1. Lymphocytes are the primary cell of the specific immune response.
2. Phagocytes are nonspecific.
3. The epithelial lining of the skin is nonspecific.
4. The GI membrane is nonspecific.
Which vaccine is initially administered in the scheduled series of vaccinations?
1. Hepatitis B
2. Meningococcal conjugate
3. Diphtheria, tetanus, and pertussis
4. Measles, mumps, and rubella
Answer: 1
Explanation:
1. Hepatitis B is the first vaccine to be administered in the scheduled series of vaccines. The first dose is received at birth.
2. Meningococcal conjugate is administered between 11 and 12 years of age.
3. The first dose of diphtheria, tetanus, and pertussis is administered at 2 months of age.
4. The first dose of measles, mumps, and rubella is administered at 12 to 15 months of age.
The educator has reviewed the use for immunosuppressants with a nurse. Which statements made by the nurse indicate an understanding of the information?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
1. "Immunosuppressants prevent tissue rejection."
2. "Immunosuppressants treat severe inflammatory diseases."
3. "Immunosuppressants dampen the immune response."
4. "Immunosuppressants stimulate new immunity."
5. "Immunosuppressants eradicate the immune system."
Answer: 1, 2, 3
Explanation:
1. Immunosuppressants prevent tissue rejection.
2. Immunosuppressants treat severe inflammatory diseases
3. Immunosuppressants dampen the immune response.
4. Immunosuppressants do not stimulate new immunity.
5. Immunosuppressants do not eradicate the immune system."