NCLEX Immune System Questions
Question 1 of 5.
The client newly diagnosed with multiple sclerosis (MS) states, 'I don't understand how I got multiple sclerosis. Is it genetic?' On which statement should the nurse base the response?
A. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus.
B. There is no evidence suggesting there is any chromosomal involvement in developing MS.
C. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS.
D. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.
Explanation: MS has a genetic susceptibility component (e.g., HLA genes), but environmental factors like viral infections may trigger it. There is chromosomal involvement, MS is not purely recessive or dominant, and it is not Y-linked.
Question 2 of 5.
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis 'anticipatory grieving related to progressive loss.' Which intervention should be implemented first?
A. Consult the physical therapist for assistive devices for mobility.
B. Determine if the client has a legal power of attorney.
C. Ask if the client would like to talk to the hospital chaplain.
D. Discuss the client's wishes regarding end-of-life care.
Explanation: Addressing anticipatory grieving involves exploring spiritual or emotional support, like a chaplain visit. Mobility devices, legal documents, and end-of-life discussions are secondary.
Question 3 of 5.
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
A. Discuss discontinuing the proton pump inhibitor with the HCP.
B. Hold the medication until after all cultures have been obtained.
C. Monitor the client's serum blood glucose levels frequently.
D. Provide supplemental dietary sodium with the client's meals.
Explanation: High-dose corticosteroids can cause hyperglycemia, requiring frequent glucose monitoring. Proton pump inhibitors are unrelated, cultures are not needed, and sodium supplementation is unnecessary.
Question 4 of 5.
Which statement by the client supports the diagnosis of Guillain-Barré syndrome?
A. I just returned from a short trip to Japan.
B. I had a really bad cold just a few weeks ago.
C. I think one of the people I work with had this.
D. I have been taking some herbs for more than a year.
Explanation: A recent viral infection (e.g., cold) is a common trigger for Guillain-Barré syndrome. Travel, coworker illness, and herbs are less relevant.
Question 5 of 5.
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem 'impaired physical mobility.' Which long-term goal should be written for this problem?
A. The client will have no skin irritation.
B. The client will have no muscle atrophy.
C. The client will perform range-of-motion exercises.
D. The client will turn every two (2) hours while awake.
Explanation: Performing range-of-motion exercises is a measurable long-term goal to improve mobility. Skin irritation, atrophy prevention, and turning are interventions, not goals.