Immune System NCLEX | Nurselytic

Questions 29

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Question 1 of 5

The client diagnosed with Guillain-Barré syndrome is admitted to the rehabilitation unit after 23 days in the acute care hospital. Which interventions should the nurse implement? Select all that apply.

Correct Answer: A,C,D,E

Rationale: Physical therapy, social worker consult, pain control, and foundation referral address mobility, psychosocial needs, comfort, and education. Speech therapy is unnecessary without communication issues.

Question 2 of 5

Which intervention should the nurse implement for the client diagnosed with systemic sclerosis (scleroderma)?

Correct Answer: B

Rationale: Frequent moisturizers combat skin fibrosis in scleroderma. Artificial tears are for Sjögren’s, braces are unrelated, and smoking cessation is secondary.

Question 3 of 5

Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections?

Correct Answer: D

Rationale: Standard Precautions reduce transmission of all infections by assuming all patients are infectious. Contact, airborne, and droplet precautions are for specific transmission modes.

Question 4 of 5

The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE?

Correct Answer: A

Rationale: Pericardial friction rub and lung crackles indicate serositis, common in SLE. Spasticity, hirsutism, and somnolence suggest other conditions.

Question 5 of 5

The client diagnosed with Guillain-Barré syndrome asks the nurse, 'Will I ever get back to normal? I am so tired of being sick.' Which statement is the best response by the nurse?

Correct Answer: A

Rationale: Most clients with Guillain-Barré syndrome recover fully within months to a year. Residual disability is less common, deferring to the team avoids education, and one-month recovery is unrealistic.

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