NCLEX-PN
NCLEX Immune System Questions Questions
Extract:
Question 1 of 5
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
Correct Answer: C
Rationale: High-dose corticosteroids can cause hyperglycemia, requiring frequent glucose monitoring. Proton pump inhibitors are unrelated, cultures are not needed, and sodium supplementation is unnecessary.
Question 2 of 5
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem 'impaired physical mobility.' Which long-term goal should be written for this problem?
Correct Answer: C
Rationale: Performing range-of-motion exercises is a measurable long-term goal to improve mobility. Skin irritation, atrophy prevention, and turning are interventions, not goals.
Question 3 of 5
Which intervention has the highest priority when caring for a client diagnosed with rheumatoid arthritis?
Correct Answer: D
Rationale: Hot and cold therapy directly relieves RA pain, a priority. Emotional ventilation, career impact, and morning activity are secondary.
Question 4 of 5
The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention?
Correct Answer: A
Rationale: Hypotension (BP 94/60) and tachycardia (AP 112) during plasmapheresis suggest hypovolemia or reaction, requiring immediate intervention. Negative signs, normal potassium, and ecchymosis are less urgent.
Question 5 of 5
The client newly diagnosed with multiple sclerosis (MS) states, 'I don't understand how I got multiple sclerosis. Is it genetic?' On which statement should the nurse base the response?
Correct Answer: A
Rationale: MS has a genetic susceptibility component (e.g., HLA genes), but environmental factors like viral infections may trigger it. There is chromosomal involvement, MS is not purely recessive or dominant, and it is not Y-linked.