NCLEX-PN
Immune System NCLEX Questions
Extract:
Question 1 of 5
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply.
Correct Answer: C,D,E
Rationale: MS causes dysmetria (impaired coordination), fatigue, and dysphagia due to neurological damage. Muscle flaccidity is atypical (spasticity is common), and lethargy is non-specific.
Question 2 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 3 of 5
The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority?
Correct Answer: B
Rationale: Voiding before a lumbar puncture prevents discomfort and reduces complications. NPO is unnecessary, lithotomy is incorrect, and pedal pulse is irrelevant.
Question 4 of 5
Which client problem is priority for a client diagnosed with RA?
Correct Answer: C
Rationale: Chronic pain (alteration in comfort) is a hallmark of RA, impacting quality of life. Activity intolerance, fluid balance, and nutrition are secondary.
Question 5 of 5
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
Correct Answer: A
Rationale: Preventing choking is critical due to dysphagia in myasthenia gravis. Ventilator care, ROM, and feeding tubes are less common or secondary.