NCLEX Questions on Immune System
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Question 1 of 5.
The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing?
A. Tapering the medication prevents the client from having withdrawal symptoms.
B. So the thyroid gland starts working, because this medication stops it from working.
C. Tapering the dose allows the adrenal glands to begin to produce cortisol again.
D. This is the health-care provider's personal choice in prescribing the medication.
Explanation: Tapering steroids allows adrenal glands to resume cortisol production, preventing adrenal insufficiency. Withdrawal symptoms are secondary, thyroid is unaffected, and it's not provider preference.
Question 2 of 5.
The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client?
A. Have you experienced any difficulty with your menstrual cycle?
B. Have you noticed a rash across the bridge of your nose?
C. Do you get tired easily and sometimes have problems swallowing?
D. Are you taking birth control pills to prevent conception?
Explanation: Fatigue and dysphagia are MS symptoms, and their presence supports the diagnosis. Menstrual issues, rashes (SLE-related), and birth control are less relevant to MS.
Question 3 of 5.
The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance?
A. The client refuses to have a gastrostomy feeding.
B. The client wants to discuss if she should tell her fiancé.
C. The client tells the nurse life is not worth living anymore.
D. The client needs the flu and pneumonia vaccines.
Explanation: Suicidal ideation indicates a mental health crisis, requiring immediate intervention. Gastrostomy refusal, disclosure to fiancé, and vaccines are less urgent.
Question 4 of 5.
The nurse writes the client problem of 'altered sexual functioning' for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented?
A. Encourage the couple to explore alternative ways of maintaining intimacy.
B. Make an appointment with a psychotherapist to counsel the couple.
C. Explain daily exercise will help increase libido and sexual arousal.
D. Discuss the importance of keeping physically calm during sexual intercourse.
Explanation: Exploring alternative intimacy methods addresses MS-related sexual dysfunction holistically. Psychotherapy is secondary, exercise may not improve libido, and physical calm is vague.
Question 5 of 5.
Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome?
A. Assess deep tendon reflexes.
B. Complete a Glasgow Coma Scale.
C. Check for Babinski's reflex.
D. Take the client's vital signs.
Explanation: Decreased deep tendon reflexes are a hallmark of Guillain-Barré syndrome due to peripheral nerve involvement. Glasgow Coma Scale, Babinski's reflex, and vital signs are less specific.