Hematological & ImmuneChapter 18December 22, 2014
18-1 Which ethnic group has the highest overallcancer incidence rate?
A. Native Americans
B. Asian and Pacific Islanders
C. Hispanics
D. African Americans
18-1 Answer D: African Americans have the highest overall cancerincidence rate and the highest overall cancermortality rate. Native Americans have the lowestoverall cancer incidence and mortality rate of allof the populations in the United States. Asian andPacific Islanders have a high rate of nasopharyngealcancer. There is a high rate of gallbladder canceramong New Mexico Hispanics of Native Americanancestry; liver cancer is more prevalent amongMexican Americans; and cervical cancer is moreprevalent among women from Central and SouthAmerica.
18-2 Physiological changes in the immune systemof older adults include
A. an increase in immunoglobulin A and G antibodies.
B. a high rate of T-lymphocyte proliferation.
C. an increase in the number of cytotoxic T cells.
D. an increase in CD8, which affects regulation ofthe immune system.
18-2 Answer A: Older adults have a change in theirimmunoglobulin (Ig) balance and a markedincrease in IgA and IgG antibodies. Otherphysiological changes in the immune systems ofolder adults include a low rate of T-lymphocyteproliferation in response to a stimulus, a decrease in the number of cytotoxic (killer) T cells, and adecrease in the relative production of CD4 (T4 orhelper T cells) and CD8, affecting regulation of theimmune system.
18-3 The first choice of therapy for a client who ispositive for HIV and has oral candidiasis is
A. fluconazole (Diflucan) 100 mg PO daily.
B. ketoconazole (Nizoral) 200 mg PO daily.
C. clotrimazole troches (10 mg) five times daily or nystatin (Mycostatin) suspension 500,000 – 1,000,000 units three to five times daily.
D. griseofulvin (Grisactin) 500 mg bid.
18-3 Answer C: The first choice of therapy for a client who isHIV positive and has oral candidiasis would beclotrimazole troches (10 mg) five times dailyor nystatin (Mycostatin) suspension 500,000 –1,000,000 units three to five times daily. Becauseof the common recurrence of oral candidiasisand increased rates of drug resistance, systemicfungicides, such as fluconazole, ketoconazole, andgriseofulvin, should be reserved for severe cases,such as esophageal candidiasis and clients withdysphagia. Clotrimazole troches and nystatinsuspension are the only nonsystemic medicationslisted.
18-4 Which of the following is a benignneoplasm?
A. Leiomyoma
B. Osteosarcoma
C. Glioma
D. Seminoma
18-4 Answer A: A leiomyoma is a benign neoplasm of the smoothmuscle. An osteosarcoma is a malignant neoplasm ofthe bone tissue, a glioma is a malignant neoplasm ofthe neuroglia cells, and a seminoma is a malignanttumor of the germ cells of the ectoderm andendoderm.
18-5 You suspect that your new client Doug has Hepatitis C, although he is currentlyasymptomatic. Your suspicion is based on hismedical history, which includes which of thefollowing factors that has been identified as a red flag for this disease?
A. Lactose intolerance
B. Frequent sore throats and upper respiratoryinfections
C. A history of mononucleosis at age 17
D. Unsafe sexual behaviors
18-5 Answer D: Identified risk factors for Hepatitis C virus (HCV)are intravenous drug use and, to some extent,unsafe sexual behaviors. Previously associatedwith transfusions before 1990 and with dialysis,the proportion of the population with these riskfactors is now less common. High-risk sexualbehaviors, particularly sex with someone infectedwith HCV, and the use of illegal drugs such ascocaine or marijuana have also been associatedwith increased risk. Lactose intolerance, a historyof mononucleosis, and a history of sore throatsand frequent upper respiratory infections are notdocumented risk factors for HCV.
18-6 Tobacco has been linked to which of thefollowing types of cancer?
A. Colon cancer
B. Bladder cancer
C. Prostate cancer
D. Cervical cancer
18-6 Answer B: Tobacco use has been linked to an increased riskfor bladder, pancreatic, laryngeal, esophageal,oropharyngeal, and some types of gastric cancer.
Persons who smoke pipes and cigars are especiallysusceptible to oropharyngeal and laryngeal cancers.Those who chew tobacco are especially susceptibleto oral and esophageal cancers. Colon cancer,cervical cancer, and prostate cancer have not beenlinked to tobacco use.
18-7 Prostate cancer is associated with whichof the following viruses?
A. Herpes simplex virus types 1 and 2
B. Human herpesvirus 6
C. Human cytomegalovirus
D. Human T-lymphotropic viruses
18-7 Answer C: Prostate cancer is associated with the humancytomegalovirus. Carcinoma of the lip, cervicalcarcinoma, and Kaposi’s sarcoma are all associated
with herpes simplex virus types 1 and 2; lymphomais associated with human herpesvirus 6; and adultT-cell leukemia and lymphoma, T-cell variantof hairy cell leukemia, and Kaposi’s sarcoma areassociated with human T-lymphotropic viruses.
18-8 What does shift to the left or left shift mean?
A. A rise in basophils
B. A rise in monocytes
C. A rise in neutrophils
D. A rise in lymphocytes
18-8 Answer C: A shift to the left or left shift indicates an elevatedwhite blood count (WBC) count and a relativeincrease in segmented and band neutrophils.Usually seen in acute bacterial infections, itindicates clinically that the body is responding to anacute need before the neutrophils can fully maturein the bone marrow. The term originated from theShilling hemogram, which charted the maturationof the granulocytes from the least mature (blasts) onthe left to most mature (segmented neutrophils) onthe right. To represent the border between the bonemarrow and the circulating blood, a line was drawnbetween the band neutrophils and the segmentedones. When the body releases immature cells intothe circulating blood, there is an increase in thecells in the circulating blood from the left of the line(left shift). Early hand devices for counting bloodcells in a differential had the keys lined up in sucha way that the technicians had to move their handto the left to hit the keys for the more immaturegranulocytes.
18-9 What is the earliest visual sign of oral andpharyngeal squamous cell carcinomas?
A. Leukoplakia
B. Mucosal erythroplasia
C. Loss of sensation in the tongue
D. Difficulty chewing or swallowing
18-9 Answer B: Mucosal erythroplasia (red inflammatory lesions)is the earliest visual sign of oral and pharyngealsquamous cell carcinomas. Leukoplakia (thickenedwhitish patches on the tongue or mucousmembranes) is the most common premalignantlesion, but only about 30% of people with theselesions are later found to have malignancy. Othersymptoms, which typically appear after mucosalerythroplasia, include pain in the face, jaw, or ear;bleeding; stuffy nose; sore throat; loss of sensationin the tongue; difficulty chewing or swallowing; or afeeling of a mass in the mouth or throat.
18-10 Select a statement that is true about theerythrocyte sedimentation rate (ESR).
A. It is a very specific indicator of inflammation.
B. A rise in the ESR is a normal part of aging.
C. It is useful in detecting pancreatic cancer.
D. It is diagnostic for rheumatoid arthritis.
18-10 Answer B: The erythrocyte sedimentation rate (ESR) is avery nonspecific indicator of inflammation and isoften elevated in inflammatory musculoskeletalconditions; it is not, however, diagnostic forrheumatoid arthritis. Additionally, anemia cancause an increased ESR. As people age, their“normal” sedimentation rate increases.
18-11 Samantha is being given platelets becauseof acute leukemia. One “pack” of platelets shouldraise her count by how much?
A. 2,000 – 4,000 mm3
B. 5,000 – 8,000 mm3
C. 9,000 – 12,000 mm3
D. About 15,000 mm3
18-11 Answer B: One pack of platelets should raise the count by 5,000 – 8,000 mm3. One pack equals about 50 mL.A “6-pack” is a pool of platelets from six unitsof blood. Platelets may be given for decreasedproduction of or destruction of platelets, such asoccurs in aplastic anemia, acute leukemia, or afterchemotherapy.
18-12 Pernicious anemia is a result of
A. not enough folic acid.
B. not enough intrinsic factor.
C. not enough vitamin D.
D. not enough iron.
18-12 Answer B: Pernicious anemia is a result of the parietal cellsof the stomach lining failing to secrete enoughintrinsic factor to ensure intestinal absorption ofvitamin B12. A deficiency of folic acid in a pregnantwoman can contribute to the development of neuraltube defects in the fetus. It can also lead to a slowlyprogressive type of anemia known as megaloblasticanemia in which the red blood cells are larger thannormal and deformed and have a diminished rate ofproduction and a diminished life span. A deficiencyin vitamin D interferes with use of calcium andphosphorus in bone and tooth formation andcan lead to osteomalacia in adults and ricketsin children. A deficiency in iron results in irondeficiencyanemia with insufficient hemoglobin;symptoms include pallor of the skin and nail-beds,fatigue, and weakness.
18-13 The gold standard for definitive diagnosisof sickle cell anemia (SCA) is
A. a reticulocyte count.
B. the sickle cell test.
C. a hemoglobin electrophoresis.
D. a peripheral blood smear.
18-13 Answer C: The gold standard for definitive diagnosis of sicklecell anemia is a hemoglobin electrophoresis, a testthat determines the presence of hemoglobin S.
The client with sickle cell anemia has a decreasedhematocrit level, as well as sickled cells on thesmear. The baseline reticulocyte count is markedlyelevated in sickle cell anemia, but that is notspecific to the condition. The sickle cell test is ascreening test. A peripheral blood smear is used forred cell morphology. Additional testing is alwaysrequired to define the hemoglobin phenotype.
18-14 A client with HIV infection has a CD4 countof 305 and an HIV RNA level of 13,549. The clientis asymptomatic. What is your course of action?
A. Negotiate with your client a time to start therapy.
B. Recheck the laboratory results in 1 month. If thecounts remain like this, start treatment.
C. Start therapy now because the client’s CD4 count is less than 500 and the HIV RNA level is greater than 10,000.
D. Wait to start therapy until the client becomesasymptomatic.
18-14 Answer C: Regardless of whether the client is symptomatic,the Centers for Disease Control and Preventionstandards call for therapy to be started when a clientwith HIV infection has a CD4 count less than 500and a HIV RNA level greater than 10,000.
18-15 Which of the following indicates that Jim,a 32-year-old client with AIDS, has oropharyngealcandidiasis?
A. Small vesicles
B. Fissured, white, thickened patches
C. Removable white plaques
D. Flat-topped papules with thin, bluish-whitespider-web lines
18-15 Answer C: Oral candidiasis (thrush) appears as white plaquesthat can be scraped off (removed), revealing anerythematous mucosal surface. Because of this,it is often referred to as a pseudomembranouslesion. Herpes simplex is an acute viral diseasethat causes small vesicles on the lip borders (coldsores). Leukoplakia is a disease of the mucousmembranes of the cheeks, gums, or tongue withwhite, thickened, fissured patches that may becomemalignant. Flat-topped papules with thin, bluish-whitespider-web lines are lesions of lichen planus,an inflammatory pruritic benign disease of the skinand mucous membranes.
18-16 Systemic lupus erythematosus is diagnosedon the basis of
A. positive antinuclear antibody (ANA), malar rash, and photosensitivity.
B. positive ANA, weight loss, and night sweats.
C. negative ANA, photosensitivity, and renal disease.
D. leukopenia, negative ANA, and photosensitivity.
18-16 Answer A: Systemic lupus erythematosus (SLE) is a multisystemautoimmune disease of unknown etiology. Accordingto the American College of Rheumatology, 4 of
11 criteria must be present at some point throughthe course of the disease. These include positive antinuclear antibody; malar rash; photosensitivity;renal disease; neurological disorders, especially seizures and psychosis; oral or nasal ulcers; non-erosive arthritis with inflammation; pleuritis or pericarditis;hematological disorder, specifically hemolytic anemia with reticulocytosis, leukopenia (WBC less than4,000 on two occasions), lymphopenia (less than 1,500 on two occasions), or thrombocytopenia (less than 100,000 on two occasions); and immunological disorder, specifically anti-DNA antibody, anti-Sm antibody, and antiphospholipid antibody, including false-positive syphilis. Weight loss and night sweatsare not diagnostic for SLE.
18-17 Which of the following situations mightprecipitate a sickle cell crisis in an infant?
A. Taking the infant to visit a relative
B. Hepatitis B immunization
C. Taking the infant to an outdoor event
D. Having the infant sleep on its back
18-17 Answer C: Certain precautions must be taken for infantswith sickle cell disease to prevent vaso-occlusivecrisis. Any activity or situation that would causedehydration should be avoided. An example issitting in a stroller in the heat for any length oftime. Children with the disease should always haveaccess to fluids. Exposure to cold temperatures slowsthe circulation and can cause sickling, as can anyactivity that can lead to hypoxia. Immunization forhepatitis B should be done. The infant can be takento visit relatives, although some care should betaken to avoid exposure to children and adults withupper respiratory infections (URIs).
18-18 Despite successful primary prophylaxis, whichinfection remains a common AIDS-defining diagnosis?
A. Pneumocystis jiroveci pneumonia (PCP)
B. Cryptococcosis
C. Cryptosporidiosis
D. Candidiasis
18-18 Answer A: Before the appearance of AIDS, Pneumocystisjiroveci pneumonia (PCP) was a rare disease thatimmunosuppressed persons and clients withleukemia sometimes developed. Today, PCP isusually the defining characteristic in clients with
AIDS in both the United States and Europe.Cryptococcosis is a life-threatening systemic fungalinfection that usually targets the central nervoussystem and the lungs, although it may attackanywhere. Cryptosporidiosis is a protozoal infectionresponsible for diarrhea in clients with AIDS. Candidiasis is the most common fungal infection,affecting 90% of all clients with AIDS, although itis common in the general population as well.
18-19 Jimmy is a 6-month-old with newlydiagnosed sickle cell disease. His mother bringshim to the clinic for a well-baby visit. Which of thefollowing should you do on this visit?
A. Tell the parents that Jimmy will not beimmunized because of his diagnosis.
B. Tell the parents that Jimmy should not go to daycare.
C. Immunize Jimmy with diphtheria, tetanus, and pertussis; Haemophilus influenzae type b (HIB); hepatitis B (HBV); and poliomyelitis vaccines.
D. Immunize Jimmy with measles, mumps, andrubella; HIB; and HBV vaccines only.
18-19 Answer C: At 6 months of age, Jimmy should be immunizedwith diphtheria, tetanus, and pertussis (DTP);Haemophilus influenzae type b (HIB); hepatitis
B (HBV); and poliomyelitis vaccines. Childrenwith sickle cell disease should receive all thestandard well-baby care, but in addition to thestandard immunizations, they should receive thepneumococcal vaccine at age 2 years. There is nocure for this disease. Children should be treated likeother children, and their activities should not belimited unless they are experiencing a painful sicklecell crisis.
18-20 The Centers for Disease Control andPrevention’s definition of AIDS includes thepresence of which of the following disorders, with orwithout laboratory evidence of HIV infection?
A. Pneumonia in clients younger than age 60
B. Dementia in clients younger than age 60
C. Kaposi’s sarcoma in clients younger than age 60
D. Primary brain lymphoma in clients older thanage 60
18-20 Answer C: Kaposi’s sarcoma in a client younger than age 60is considered conclusive evidence of AIDS underthe Centers for Disease Control and Prevention’sdefinition. Other disorders, with or withoutlaboratory evidence of HIV infections thatalso define AIDS, include Pneumocystis jirovecipneumonia; candidiasis of the esophagus, trachea,bronchi, or lungs; extrapulmonary cryptococcosis;cryptosporidiosis with persistent diarrhea;cytomegalovirus infection; herpes simplex virusinfection with persistent skin lesions; Mycobacteriumavium infection; progressive multifocalleukoencephalopathy; toxoplasmosis of the brain;and primary lymphoma of the brain in a clientyounger than age 60.
18-21 A loss of DNA control over differentiationthat occurs in response to adverse conditions isreferred to as
A. hyperplasia.
B. metaplasia.
C. anaplasia.
D. dysplasia.
18-21 Answer D: A loss of DNA control over differentiationoccurring in response to adverse conditions isreferred to as dysplasia. Dysplastic cells show an abnormal degree of variation in size, shape, and appearance and a disturbance in the usual arrangement. An example of dysplasia is a change inthe cervix in response to the human papillomavirus. Hyperplasia is an increase in the number or densityof normal cells. Hyperplasia occurs in response tostress, increased metabolic demands, or elevatedlevels of hormones. An example of hyperplasia isthe change in uterine cells in response to risinglevels of estrogen during pregnancy. Metaplasia isa change in the normal pattern of differentiationsuch that dividing cells differentiate into cell typesnot normally found in that location in the body. Anexample of metaplasia is the replacement of normalcolumnar ciliated cells in the bronchial epitheliumby stratified squamous cells in response to inhaledpollutants, primarily cigarette smoke. Anaplasiais the regression of a cell to an immature orundifferentiated cell type. Anaplastic cell divisionis no longer under DNA control. It usually occurswhen a damaging or transforming event takes placeinside the dividing, but still undifferentiated, cell.An example of anaplasia may be a response to anoverwhelmingly destructive condition inside thecell or in the surrounding tissue.
18-22 Clients with AIDS typically experiencethe neurological symptomatic triad consisting of
A. cognitive, motor, and behavioral changes.
B. seizures, paresthesias, and dysesthesias.
C. Kaposi’s sarcoma, cryptococcal meningitis, anddepression.
D. seizures, depression, and paresthesias.
18-22 Answer A: Certainly all of the possible answer options listedmay occur in clients with AIDS. However, the keyword in the stem of the question is neurological. Theneurological symptomatic triad that clients withAIDS typically experience consists of cognitive,motor, and behavioral changes. These changes arepresent to a greater or lesser degree in all clientswith AIDS. Kaposi’s sarcoma is not neurological; itis a multifocal neoplasm with vascular tumors in theskin and other organs.
18-23 When a neonate is initially protectedagainst measles, mumps, and rubella because themother is immune, this is an example of which typeof immunity?
A. Natural active
B. Artificial active
C. Natural passive
D. Artificial passive
18-23 Answer C: When a neonate is initially protected againstmeasles, mumps, and rubella (MMR) because themother is immune, this is an example of naturalpassive immunity. This type of immunity is acquiredby the transfer of maternal antibodies to thefetus or neonate via the placenta or breast milk.Chickenpox and hepatitis A are examples of naturalactive immunity, which is acquired by infectionwith an antigen, resulting in the production ofantibodies. MMR, polio, diphtheria, pertussis,tetanus, and hepatitis B vaccines are examples ofartificial active immunity, which is acquired byimmunization with an antigen, such as attenuatedlive virus vaccine. A gamma globulin injectionfollowing hepatitis A exposure is an example ofartificial passive immunity, which is acquired byadministration of antibodies or antitoxins in theimmune globulin.
18-24 Your client, Ms. Jones, has an elevatedplatelet count. You suspect
A. systemic lupus erythematosus.
B. infectious mononucleosis.
C. disseminated intravascular coagulation (DIC).
D. splenectomy.
18-24 Answer D: Increased platelet count is seen inmyeloproliferative leukemias, polycythemia vera,and status post-splenectomy. Platelets are decreasedin coagulation disorders such as disseminatedintravascular coagulation (DIC), septicemia, andeclampsia; increased destruction of platelets isseen in idiopathic thrombocytopenic purpura,systemic lupus erythematosus (SLE), and infectiousmononucleosis; and decreased production ofplatelets is seen in aplastic anemia, most leukemias,and secondary to radiation and chemotherapy.