NCLEX-RN
Immunity NCLEX Questions Questions
Question 1 of 5
The nurse in the outpatient clinic is assessing a client with systemic lupus erythematosus (SLE). Which laboratory data is essential for the nurse to monitor to determine if the client is experiencing a complication?
Correct Answer: A
Rationale: Urine analysis is essential for monitoring complications in SLE, as it can detect proteinuria or hematuria, which are indicative of lupus nephritis, a common and serious complication. HbA1C is related to diabetes management, TSH to thyroid function, and ammonia to liver function, none of which are primary concerns for SLE complications.
Question 2 of 5
The nurse is assessing a client who has Raynaud's phenomenon. Which of the following would be an expected finding?
Correct Answer: A
Rationale: Raynaud's phenomenon is characterized by digit color changes (white, blue, red) due to vasospasms triggered by cold or stress. Flapping hand tremors are associated with liver disease, painless skin ulcers with venous insufficiency, and Janeway lesions with endocarditis, none of which are typical of Raynaud's.
Extract:
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 1 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Question 3 of 5
Which of the following assessment findings require immediate follow-up? Select all that apply.
Correct Answer: A,B,D,F,G
Rationale: Given the client's severe SLE exacerbation, chest pain, pallor, and diaphoresis, immediate follow-up is needed for lung sounds (
A) to assess for pulmonary issues like pleural effusion, cardiac sounds (
B) for pericarditis or tamponade, blood pressure (
D) for hemodynamic stability, pulse oximetry (F) for oxygenation, and pulse (G) for cardiovascular status. Temperature (
C) and butterfly rash (E) are less urgent in this acute context.
Extract:
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 2 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Question 4 of 5
Which of the following issues is the client at risk of developing? Select all that apply.
Correct Answer: A,B,C,E
Rationale: SLE increases the risk of cardiac tamponade (
A) due to pericarditis, cardiogenic shock (
B) from cardiac involvement, stroke (
C) from antiphospholipid syndrome, and acute coronary syndrome (E) from accelerated atherosclerosis. Pneumothorax (
D) is not a typical SLE complication.
Extract:
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 3 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Question 5 of 5
The client is most likely experiencing ………………..
Correct Answer: C
Rationale: Given the client's SLE history, chest pain, and lack of ST-elevations or troponin elevation, cardiac tamponade is the most likely diagnosis, as SLE can cause pericarditis leading to fluid accumulation. Acute coronary syndrome is less likely without ECG or troponin changes, and pneumothorax is not supported by the scenario.