Immune System NCLEX Questions

Extract:

Question 1 of 5

The nurse is caring for a client who has Systemic Inflammatory Response Syndrome (SIRS) following a major abdominal surgery. Which signs and symptoms would the nurse observe that indicate SIRS? Select all that apply.

Correct Answer: A,B,D

Rationale: SIRS presents with coagulopathy (bleeding/platelet issues), renal dysfunction (oliguria, high osmolality), and altered mental status. Pitting edema and normal vital signs are not diagnostic.

Question 2 of 5

The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?

A. Encourage the therapy if it is not contraindicated by the medical regimen. B. Tell the client only the health-care provider should discuss this with him. C. Ask how his significant other feels about this deviation from the medical regimen. D. Suggest the client research an investigational therapy instead.

Correct Answer: A

Rationale: Encouraging safe alternative therapies supports autonomy if they align with medical treatment. Deferring to HCP, involving significant other, or suggesting investigational therapies are less appropriate.

Question 3 of 5

The nurse is caring for clients on a medical floor. Which client should the nurse assess first?

A. The client diagnosed with RA complaining of pain at a '3' on a 1-to-10 scale. B. The client diagnosed with SLE who has a rash across the bridge of the nose. C. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV. D. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.

Correct Answer: C

Rationale: Antineoplastic drugs (e.g., methotrexate) pose risks like toxicity, requiring immediate assessment. Mild pain, rashes, and scleroderma are less acute.

Question 4 of 5

The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention?

A. The client has scanning speech and diplopia. B. The client has dysarthria and scotomas. C. The client has muscle weakness and spasticity. D. The client has a congested cough and dysphagia.

Correct Answer: D

Rationale: Congested cough and dysphagia indicate potential airway and swallowing issues, requiring immediate intervention to prevent aspiration or respiratory distress. Neurological symptoms like speech issues, diplopia, scotomas, weakness, and spasticity are expected in MS but less acute.

Question 5 of 5

The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE?

A. The steroids will increase the body's ability to fight the infection. B. The steroids will decrease the chance of the SLE spreading to other organs. C. The steroids will suppress tissue inflammation, which reduces damage to organs. D. The steroids will prevent scarring of skin tissues associated with SLE.

Correct Answer: C

Rationale: Steroids suppress inflammation in SLE, reducing organ damage. They do not fight infection, prevent disease spread, or address skin scarring primarily.

Immune System NCLEX Questions | Nurselytic

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