NCLEX-PN
NCLEX Immune System Questions Questions
Extract:
Question 1 of 5
The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?
Correct Answer: D
Rationale: The Tensilon test improves muscle strength in myasthenia gravis by inhibiting acetylcholinesterase. No change, electrical stimulation, or antibody levels are not diagnostic.
Question 2 of 5
The client recently diagnosed with rheumatoid arthritis is prescribed aspirin, a nonsteroidal anti-inflammatory medication. Which comment by the client warrants immediate intervention by the nurse?
Correct Answer: D
Rationale: Ringing in the ears (tinnitus) indicates aspirin toxicity, requiring immediate intervention. Taking with food, reporting dark stools, and understanding no cure are correct.
Question 3 of 5
The client diagnosed with Systemic Response Inflammatory Syndrome (SIRS) asks the nurse what the diagnosis means. Which is the nurse's best response?
Correct Answer: D
Rationale: SIRS is a systemic response to insults like infection or trauma. It is not localized, has variable prognosis, and is not solely respiratory.
Question 4 of 5
The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves?
Correct Answer: C
Rationale: Carrying nonsterile, nonlatex gloves ensures safe practice for a latex-allergic nurse. Sterile gloves are unnecessary, avoiding gloves risks infection, and cotton gloves are inadequate.
Question 5 of 5
The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response?
Correct Answer: D
Rationale: Acknowledging crying and offering to talk is therapeutic, encouraging emotional expression. Linking stress to SLE, demanding explanations, or suggesting groups are less supportive.