Immune System NCLEX
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Question 1 of 5.
The nurse is discussing autoimmune diseases with a class of nursing students. Which signs and symptoms are shared by rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)?
A. Nodules in the subcutaneous layer and bone deformity.
B. Renal involvement and pleural effusions.
C. Joint stiffness and pain.
D. Raynaud's phenomenon and skin rash.
Explanation: Joint stiffness and pain are common to both RA and SLE. Nodules and deformities are RA-specific, renal/pleural issues are more SLE-specific, and Raynaud's/rash are not universal in RA.
Question 2 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?
A. Why are you crying? The medication will help the disease.
B. You seem upset. I will sit down and we can talk for awhile.
C. Multiple sclerosis is a disease that has good times and bad times.
D. I will have the chaplain come and stay with you for a while.
Explanation: 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 3 of 5.
The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which nursing task should not be assigned to the LPN?
A. Administer a skeletal muscle relaxant to a client diagnosed with low back pain.
B. Discuss bowel regimen medications with the HCP for the client on strict bedrest.
C. Draw morning blood work on the client diagnosed with bacterial meningitis.
D. Teach self-catheterization to the client diagnosed with multiple sclerosis.
Explanation: Teaching self-catheterization requires nursing judgment and patient education, outside LPN scope. Administering medications, discussing with HCP, and drawing blood are within LPN scope.
Question 4 of 5.
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply.
A. Muscle flaccidity.
B. Lethargy.
C. Dysmetria.
D. Fatigue.
E. Dysphagia.
Explanation: MS causes dysmetria (impaired coordination), fatigue, and dysphagia due to neurological damage. Muscle flaccidity is atypical (spasticity is common), and lethargy is non-specific.
Question 5 of 5.
The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority?
A. Keep the client NPO.
B. Instruct the client to void.
C. Place in the lithotomy position.
D. Assess the client's pedal pulse.
Explanation: Voiding before a lumbar puncture prevents discomfort and reduces complications. NPO is unnecessary, lithotomy is incorrect, and pedal pulse is irrelevant.
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