NCLEX-PN
Immune System NCLEX Questions Questions
Extract:
Question 1 of 5
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome?
Correct Answer: D
Rationale: Guillain-Barré syndrome presents with ascending paralysis and numbness due to peripheral nerve demyelination. Startle reflex, rigidity, and facial pain suggest other conditions.
Question 2 of 5
Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome?
Correct Answer: D
Rationale: Ascending paralysis in Guillain-Barré syndrome risks respiratory muscle involvement, making ineffective breathing pattern the priority. Injury, anxiety, and nutrition are secondary.
Question 3 of 5
The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure?
Correct Answer: D
Rationale: Increasing fluid intake post-lumbar puncture prevents spinal headache. Hypotension is not a primary concern, pressure is applied during the procedure, and CSF testing is lab-based.
Question 4 of 5
Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis?
Correct Answer: B
Rationale: Ptosis and diplopia are hallmark ocular symptoms of myasthenia gravis due to neuromuscular weakness. General weakness, respiratory issues, and weight loss are less specific.
Question 5 of 5
Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis?
Correct Answer: D
Rationale: Speech therapists address dysphagia and communication issues in late-stage myasthenia gravis. Other therapists are less relevant.