Immunity NCLEX Questions
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Question 1 of 5.
The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock?
A. hypertension
B. crackles (rales) in the lung fields
C. cutaneous cyanosis
D. pruritus
Explanation: Anaphylactic shock is characterized by cutaneous cyanosis (C) from poor perfusion and pruritus (D) from histamine release. Hypertension (A) is not typical, as hypotension is expected. Crackles (B) suggest pulmonary edema, not a primary feature of anaphylaxis.
Question 2 of 5.
The nurse in the outpatient clinic is assessing a client with systemic lupus erythematosus (SLE). Which laboratory data is essential for the nurse to monitor to determine if the client is experiencing a complication?
A. urine analysis
B. hemoglobin A1C (HbA1C)
C. thyroid-stimulating hormone (TSH)
D. ammonia
Explanation: Urine analysis is essential for monitoring complications in SLE, as it can detect proteinuria or hematuria, which are indicative of lupus nephritis, a common and serious complication. HbA1C is related to diabetes management, TSH to thyroid function, and ammonia to liver function, none of which are primary concerns for SLE complications.
Question 3 of 5.
The nurse is assessing a client who has Raynaud's phenomenon. Which of the following would be an expected finding?
A. Digit color changes
B. Flapping hand tremor
C. Painless skin ulcers
D. Janeway lesions
Explanation: Raynaud's phenomenon is characterized by digit color changes (white, blue, red) due to vasospasms triggered by cold or stress. Flapping hand tremors are associated with liver disease, painless skin ulcers with venous insufficiency, and Janeway lesions with endocarditis, none of which are typical of Raynaud's.
Question 4 of 5.
Extract:The following scenario applies to the next 6 items The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client Item 1 of 6 Admission Note Nurses' Notes Physician Orders 1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations. • The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Which of the following assessment findings require immediate follow-up? Select all that apply.
A. lung sounds
B. cardiac sounds
C. temperature
D. blood pressure
E. butterfly-shaped rash on face
F. pulse oximetry
G. pulse
Explanation: Given the client's severe SLE exacerbation, chest pain, pallor, and diaphoresis, immediate follow-up is needed for lung sounds (A) to assess for pulmonary issues like pleural effusion, cardiac sounds (B) for pericarditis or tamponade, blood pressure (D) for hemodynamic stability, pulse oximetry (F) for oxygenation, and pulse (G) for cardiovascular status. Temperature (C) and butterfly rash (E) are less urgent in this acute context.
Question 5 of 5.
Extract:The following scenario applies to the next 6 items The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client Item 2 of 6 Admission Note Nurses' Notes Physician Orders 1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations. • The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Which of the following issues is the client at risk of developing? Select all that apply.
A. cardiac tamponade
B. cardiogenic shock
C. stroke
D. pneumothorax
E. acute coronary syndrome
Explanation: SLE increases the risk of cardiac tamponade (A) due to pericarditis, cardiogenic shock (B) from cardiac involvement, stroke (C) from antiphospholipid syndrome, and acute coronary syndrome (E) from accelerated atherosclerosis. Pneumothorax (D) is not a typical SLE complication.
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