Immune System NCLEX Questions

Question 1 of 5

The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention?

A. The client has scanning speech and diplopia.B. The client has dysarthria and scotomas.C. The client has muscle weakness and spasticity.D. The client has a congested cough and dysphagia.

Correct Answer: D

Rationale: Congested cough and dysphagia indicate potential airway and swallowing issues, requiring immediate intervention to prevent aspiration or respiratory distress. Neurological symptoms like speech issues, diplopia, scotomas, weakness, and spasticity are expected in MS but less acute.

Question 2 of 5

The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test?

A. The client will have wires attached to the scalp and lights will flash off and on.B. The machine will be loud and the client must not move the head during the test.C. The client will drink a contrast medium 30 minutes to one (1) hour before the test.D. The test will be repeated at intervals during a five (5)- to six (6)-hour period.

Correct Answer: B

Rationale: MRI machines are loud, and head immobility is critical for clear images. Wires/lights describe EEG, oral contrast is not used for brain MRI, and the test is not repeated over hours.

Question 3 of 5

The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?

A. Encourage the therapy if it is not contraindicated by the medical regimen.B. Tell the client only the health-care provider should discuss this with him.C. Ask how his significant other feels about this deviation from the medical regimen.D. Suggest the client research an investigational therapy instead.

Correct Answer: A

Rationale: Encouraging safe alternative therapies supports autonomy if they align with medical treatment. Deferring to HCP, involving significant other, or suggesting investigational therapies are less appropriate.

Question 4 of 5

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome?

A. An exaggerated startle reflex and memory changes.B. Cogwheel rigidity and inability to initiate voluntary movement.C. Sudden severe unilateral facial pain and inability to chew.D. Progressive ascending paralysis of the lower extremities and numbness.

Correct Answer: D

Rationale: Guillain-Barré syndrome presents with ascending paralysis and numbness due to peripheral nerve demyelination. Startle reflex, rigidity, and facial pain suggest other conditions.

Question 5 of 5

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome?

A. High risk for injury.B. Fear and anxiety.C. Altered nutrition.D. Ineffective breathing pattern.

Correct Answer: D

Rationale: Ascending paralysis in Guillain-Barré syndrome risks respiratory muscle involvement, making ineffective breathing pattern the priority. Injury, anxiety, and nutrition are secondary.

Immune System NCLEX Questions | Nurselytic

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