NCLEX-PN
Immune System NCLEX Questions
Extract:
Question 1 of 5
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction?
Correct Answer: D
Rationale: Establishing a patent airway is the highest priority in anaphylaxis, per ABCs. Epinephrine, intubation, and reassurance follow.
Question 2 of 5
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority?
Correct Answer: D
Rationale: HIV encephalopathy increases confusion and motor deficits, making risk for injury the priority. Nutrition, grieving, and knowledge are secondary.
Question 3 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.
Question 4 of 5
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make?
Correct Answer: B
Rationale: Acknowledging the client’s distress and offering to talk is therapeutic, fostering emotional support. 'Why' questions are confrontational, disease facts dismiss feelings, and chaplain referral is premature.
Question 5 of 5
The client is prescribed a prick epicutaneous test to determine the cause of hypersensitivity reactions. Which result indicates the client is hypersensitive to the allergen?
Correct Answer: D
Rationale: A pruritic wheal and erythema at the prick site indicate a positive allergic response. Shortness of breath is systemic, dry skin is negative, and blood tests are separate.