NCLEX-PN
NCLEX Immune System Questions Questions
Extract:
Question 1 of 5
The client diagnosed with an anaphylactic reaction is admitted to the emergency department. Which assessment data indicate the client is not responding to the treatment?
Correct Answer: B
Rationale: Hypotension (BP 90/60) and tachycardia (AP 110) indicate ongoing anaphylaxis despite treatment. Normal urine output, clear lungs, and bowel sounds suggest improvement.
Question 2 of 5
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis 'anticipatory grieving related to progressive loss.' Which intervention should be implemented first?
Correct Answer: C
Rationale: Addressing anticipatory grieving involves exploring spiritual or emotional support, like a chaplain visit. Mobility devices, legal documents, and end-of-life discussions are secondary.
Question 3 of 5
The client recently diagnosed with SLE asks the nurse, 'What is SLE and how did I get it?' Which statement best explains the scientific rationale for the nurse's response?
Correct Answer: D
Rationale: SLE is an autoimmune disease with genetic and hormonal influences. Kidney issues are a complication, viral triggers are secondary, and the cause is partially understood.
Question 4 of 5
The client diagnosed with Multiple Organ Dysfunction Syndrome (MODS) is admitted to the intensive care department. Which assessment data are most important for the nurse to collect/monitor?
Correct Answer: A
Rationale: Lung sounds, heart sounds, and BP monitor respiratory, cardiac, and hemodynamic status, critical in MODS. Psychological, family, and GI data are secondary.
Question 5 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.