NCLEX RN Practice Exam Immune
Disorders Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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1
The nurse is caring for a client who has just been diagnosed with systemic lupus
erythematosus (SLE). Which assessment finding is most consistent with this
diagnosis?
A) Butterfly-shaped rash across the bridge of the nose and cheeks
B) Thickened, hardened skin on the extremities
C) Dry, scaly patches on the elbows and knees
D) Vesicular lesions along the dermatomes
Answer: A) Butterfly-shaped rash across the bridge of the nose and cheeks
Rationale: A malar or butterfly-shaped rash across the bridge of the nose and
cheeks is a hallmark manifestation of systemic lupus erythematosus. This rash is
photosensitive and typically spares the nasolabial folds. Option B describes
scleroderma, Option C describes psoriasis, and Option D describes herpes zoster.
The presence of a butterfly rash, along with other systemic symptoms, is highly
suggestive of SLE and requires prompt evaluation and management.
2
,A client with HIV infection is prescribed highly active antiretroviral therapy
(HAART). Which laboratory value is most important for the nurse to monitor to
evaluate the effectiveness of this therapy?
A) White blood cell count
B) CD4+ T-cell count
C) Hemoglobin and hematocrit
D) Platelet count
Answer: B) CD4+ T-cell count
Rationale: The CD4+ T-cell count is the most important laboratory value to
monitor the effectiveness of HAART in HIV-positive clients. HAART aims to
suppress viral replication and preserve immune function, which is reflected by an
increase in CD4+ T-cell counts. A rising CD4+ count indicates that the therapy is
effective in restoring immune function. While monitoring the white blood cell
count, hemoglobin, hematocrit, and platelet count is important for detecting
side effects of antiretroviral medications, the CD4+ count is the primary indicator
of immune status and treatment efficacy.
3
The nurse is providing discharge teaching to a client who has undergone an organ
transplant and is taking cyclosporine. Which statement by the client indicates a
need for further teaching?
A) "I will report any signs of infection to my healthcare provider immediately"
B) "I should avoid eating grapefruit or drinking grapefruit juice while taking this
medication"
C) "I will take my blood pressure medication as prescribed because cyclosporine
can cause hypertension"
D) "I can stop taking my medication when I start feeling better"
Answer: D) "I can stop taking my medication when I start feeling better"
,Rationale: This statement indicates a need for further teaching because
immunosuppressive medications like cyclosporine must be taken exactly as
prescribed for life following organ transplantation. Stopping the medication
when feeling better would lead to rejection of the transplanted organ. The client
must understand that immunosuppressants are taken continuously to prevent
organ rejection, regardless of how they feel. The other statements demonstrate
good understanding: reporting signs of infection (A) is correct because
immunosuppression increases infection risk, avoiding grapefruit (B) is correct
because it increases cyclosporine levels, and taking blood pressure medication
(C) is correct because cyclosporine causes hypertension.
4
A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory
test should the nurse monitor closely to detect a potential adverse effect of this
medication?
A) Serum creatinine
B) Liver function tests
C) Complete blood count with differential
D) Serum glucose
Answer: B) Liver function tests
Rationale: Methotrexate is hepatotoxic and can cause liver damage, making
liver function tests essential for monitoring. The drug can elevate liver enzymes
and, with long-term use, may lead to hepatic fibrosis or cirrhosis. Regular
monitoring of AST, ALT, alkaline phosphatase, and bilirubin is necessary. While
methotrexate also affects renal function and bone marrow, causing
myelosuppression, liver toxicity is a particularly concerning side effect that
requires consistent monitoring. Serum creatinine (A) should also be monitored
but is not the most critical, and complete blood count (C) is important but
secondary to liver function monitoring.
, 5
The nurse is assessing a client with suspected anaphylaxis following administration
of intravenous antibiotics. Which finding requires immediate intervention?
A) Mild urticaria on the chest
B) Stridor and difficulty breathing
C) Pruritus and flushing
D) Anxiety and restlessness
Answer: B) Stridor and difficulty breathing
Rationale: Stridor and difficulty breathing indicate severe airway compromise
due to laryngeal edema, which is a life-threatening manifestation of
anaphylaxis. This requires immediate intervention, including administration of
epinephrine, maintaining the airway, and preparing for possible intubation.
While urticaria, pruritus, flushing, anxiety, and restlessness are also signs of
anaphylaxis, stridor with respiratory difficulty represents the most immediate
threat to life and must be addressed first to prevent respiratory arrest.
6
A client with multiple sclerosis is experiencing an acute exacerbation. The
healthcare provider orders intravenous methylprednisolone. What is the primary
purpose of this medication during an exacerbation?
A) To prevent further demyelination of neurons
B) To reduce inflammation and shorten the duration of the exacerbation
C) To promote remyelination of damaged nerve fibers
D) To relieve muscle spasticity and pain
Answer: B) To reduce inflammation and shorten the duration of the
exacerbation
Rationale: Intravenous methylprednisolone is a high-dose corticosteroid used to
treat acute exacerbations of multiple sclerosis. Its primary purpose is to reduce
Disorders Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1
The nurse is caring for a client who has just been diagnosed with systemic lupus
erythematosus (SLE). Which assessment finding is most consistent with this
diagnosis?
A) Butterfly-shaped rash across the bridge of the nose and cheeks
B) Thickened, hardened skin on the extremities
C) Dry, scaly patches on the elbows and knees
D) Vesicular lesions along the dermatomes
Answer: A) Butterfly-shaped rash across the bridge of the nose and cheeks
Rationale: A malar or butterfly-shaped rash across the bridge of the nose and
cheeks is a hallmark manifestation of systemic lupus erythematosus. This rash is
photosensitive and typically spares the nasolabial folds. Option B describes
scleroderma, Option C describes psoriasis, and Option D describes herpes zoster.
The presence of a butterfly rash, along with other systemic symptoms, is highly
suggestive of SLE and requires prompt evaluation and management.
2
,A client with HIV infection is prescribed highly active antiretroviral therapy
(HAART). Which laboratory value is most important for the nurse to monitor to
evaluate the effectiveness of this therapy?
A) White blood cell count
B) CD4+ T-cell count
C) Hemoglobin and hematocrit
D) Platelet count
Answer: B) CD4+ T-cell count
Rationale: The CD4+ T-cell count is the most important laboratory value to
monitor the effectiveness of HAART in HIV-positive clients. HAART aims to
suppress viral replication and preserve immune function, which is reflected by an
increase in CD4+ T-cell counts. A rising CD4+ count indicates that the therapy is
effective in restoring immune function. While monitoring the white blood cell
count, hemoglobin, hematocrit, and platelet count is important for detecting
side effects of antiretroviral medications, the CD4+ count is the primary indicator
of immune status and treatment efficacy.
3
The nurse is providing discharge teaching to a client who has undergone an organ
transplant and is taking cyclosporine. Which statement by the client indicates a
need for further teaching?
A) "I will report any signs of infection to my healthcare provider immediately"
B) "I should avoid eating grapefruit or drinking grapefruit juice while taking this
medication"
C) "I will take my blood pressure medication as prescribed because cyclosporine
can cause hypertension"
D) "I can stop taking my medication when I start feeling better"
Answer: D) "I can stop taking my medication when I start feeling better"
,Rationale: This statement indicates a need for further teaching because
immunosuppressive medications like cyclosporine must be taken exactly as
prescribed for life following organ transplantation. Stopping the medication
when feeling better would lead to rejection of the transplanted organ. The client
must understand that immunosuppressants are taken continuously to prevent
organ rejection, regardless of how they feel. The other statements demonstrate
good understanding: reporting signs of infection (A) is correct because
immunosuppression increases infection risk, avoiding grapefruit (B) is correct
because it increases cyclosporine levels, and taking blood pressure medication
(C) is correct because cyclosporine causes hypertension.
4
A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory
test should the nurse monitor closely to detect a potential adverse effect of this
medication?
A) Serum creatinine
B) Liver function tests
C) Complete blood count with differential
D) Serum glucose
Answer: B) Liver function tests
Rationale: Methotrexate is hepatotoxic and can cause liver damage, making
liver function tests essential for monitoring. The drug can elevate liver enzymes
and, with long-term use, may lead to hepatic fibrosis or cirrhosis. Regular
monitoring of AST, ALT, alkaline phosphatase, and bilirubin is necessary. While
methotrexate also affects renal function and bone marrow, causing
myelosuppression, liver toxicity is a particularly concerning side effect that
requires consistent monitoring. Serum creatinine (A) should also be monitored
but is not the most critical, and complete blood count (C) is important but
secondary to liver function monitoring.
, 5
The nurse is assessing a client with suspected anaphylaxis following administration
of intravenous antibiotics. Which finding requires immediate intervention?
A) Mild urticaria on the chest
B) Stridor and difficulty breathing
C) Pruritus and flushing
D) Anxiety and restlessness
Answer: B) Stridor and difficulty breathing
Rationale: Stridor and difficulty breathing indicate severe airway compromise
due to laryngeal edema, which is a life-threatening manifestation of
anaphylaxis. This requires immediate intervention, including administration of
epinephrine, maintaining the airway, and preparing for possible intubation.
While urticaria, pruritus, flushing, anxiety, and restlessness are also signs of
anaphylaxis, stridor with respiratory difficulty represents the most immediate
threat to life and must be addressed first to prevent respiratory arrest.
6
A client with multiple sclerosis is experiencing an acute exacerbation. The
healthcare provider orders intravenous methylprednisolone. What is the primary
purpose of this medication during an exacerbation?
A) To prevent further demyelination of neurons
B) To reduce inflammation and shorten the duration of the exacerbation
C) To promote remyelination of damaged nerve fibers
D) To relieve muscle spasticity and pain
Answer: B) To reduce inflammation and shorten the duration of the
exacerbation
Rationale: Intravenous methylprednisolone is a high-dose corticosteroid used to
treat acute exacerbations of multiple sclerosis. Its primary purpose is to reduce
