NCLEX-PN
Immune System NCLEX Questions
Extract:
Question 1 of 5
Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome?
Correct Answer: D
Rationale: Recovery in Guillain-Barré syndrome shows descending muscle strength improvement. Reflexes improve, ptosis is unrelated, and Babinski’s is not typical.
Question 2 of 5
The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
Correct Answer: A
Rationale: Administering pyridostigmine 30 minutes before meals maximizes muscle strength for swallowing. Water volume, sitting up, and BP checks are not specific requirements.
Question 3 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 4 of 5
Which intervention should the nurse implement for the client diagnosed with systemic sclerosis (scleroderma)?
Correct Answer: B
Rationale: Frequent moisturizers combat skin fibrosis in scleroderma. Artificial tears are for Sjögren’s, braces are unrelated, and smoking cessation is secondary.
Question 5 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.