A nurse is preparing a plan of care for a child with a primary ...

[lb_gilbert]

A nurse is preparing a plan of care for a child with a primary immunodeficiency. Which nursing diagnosis would the nurse most likely identify as the priority?
 
  A) Imbalanced nutrition, less than body requirements related to poor appetite
  B) Ineffective protection related to impaired humoral defenses
  C) Acute pain related to inflammatory processes
  D) Risk for delayed growth and development related to chronic illness

Question 2

After teaching a class about humoral and cellular immunity, the nurse recognizes that the additional teaching is needed when the class states which of the following?
 
  A) Humoral immunity crosses the placenta.
  B) Cellular immunity involves the T lymphocytes.
  C) Cellular immunity recognizes antigens.
  D) Humoral immunity does not destroy the foreign cell.

[Rilsmarie951]

Answer to Question 1

B
Feedback:
The child with a primary immunodeficiency lacks the necessary immune responses that provide protection from infection. Therefore, the priority nursing diagnosis would be ineffective protection. Imbalanced nutrition and risk for delayed growth and development may be appropriate, but these would not be the priority. Acute pain would be more appropriate for a child with juvenile idiopathic arthritis.

Answer to Question 2

C
Feedback:
Humoral immunity recognizes antigens and cellular immunity does not. Humoral immunity crosses the placenta in the form of IgG. Cellular immunity involves the action of T lymphocytes, and humoral immunity does not destroy the foreign cell.