A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
Pitting edema of the hands and fingers
Grey colored, non-purpuric papular rash
Dry, red rash across the bridge of the nose and on the cheeks
Subcutaneous nodules on the ulnar side of the arm
The Correct Answer is C
Choice A rationale:
Pitting edema of the hands and fingers is not a typical finding in SLE. It can occur in some cases, but it is more commonly associated with other conditions such as kidney disease or heart failure.
Choice B rationale:
Grey colored, non-purpuric papular rash is not a characteristic of SLE. This type of rash is more commonly seen in conditions such as lichen planus or sarcoidosis.
Choice C rationale:
A dry, red rash across the bridge of the nose and on the cheeks, also known as a malar rash, is a classic sign of SLE. It is often described as a "butterfly rash" because of its shape. The rash is caused by inflammation of the small blood vessels in the skin. It is typically worsened by sun exposure.
Choice D rationale:
Subcutaneous nodules on the ulnar side of the arm are a characteristic finding in rheumatoid arthritis, not SLE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Exercise.
Choice A: Exercise Exercise is generally beneficial for overall health and is not typically a factor that exacerbates systemic lupus erythematosus (SLE). In fact, regular physical activity can be an important part of the overall treatment plan for individuals with SLE. It can boost energy levels, improve joint flexibility, and help alleviate stress. Therefore, if a patient with SLE identifies exercise as a factor that can exacerbate their condition, it indicates a need for further teaching.
Choice B: Diet Certain diets can potentially trigger or worsen SLE symptoms. For instance, a chemical found in alfalfa may trigger lupus symptoms, so patients may want to avoid eating alfalfa sprouts or taking supplements with alfalfa. Therefore, diet is a correct factor that can exacerbate SLE.
Choice C: Sunlight Exposure to sunlight can trigger or worsen SLE symptoms. For those with lupus, being in the sun can lead to symptoms like skin rashes, itching, burning, joint pain, weakness, and fatigue. In certain cases, it can also result in damage to internal organs. Therefore, sunlight is a correct factor that can exacerbate SLE.
Choice D: Infection Infections can trigger or worsen SLE symptoms. Rates of infections are higher among persons with SLE compared with the general population. Therefore, infection is a correct factor that can exacerbate SLE.
Correct Answer is A
Explanation
Choice A rationale:
Lymph nodes are small, bean-shaped structures that play a crucial role in the immune system. They filter lymph fluid, which carries white blood cells and other immune cells throughout the body.
When the body is fighting an infection or other immune challenge, lymph nodes often swell and become tender. This is because they are actively working to filter out pathogens and activate immune cells.
Palpation of the lymph nodes can provide valuable information about the patient's immune function. The nurse can assess for enlargement, tenderness, and mobility of the lymph nodes.
Lymph node assessment is a non-invasive, painless procedure that can be performed quickly and easily.
Choice B rationale:
Auscultation of the apical heart rate is important for assessing cardiovascular function, but it does not directly assess immune function.
While heart rate can be indirectly affected by certain immune conditions (e.g., fever), it is not a primary indicator of immune system activity.
Choice C rationale:
Palpation of the liver can provide information about liver size and consistency, but it does not directly assess immune function.
The liver plays a role in immune function by producing proteins that help fight infection, but its size and consistency do not necessarily reflect its immune activity.
Choice D rationale:
Percussion of the abdomen can be used to assess the size and location of abdominal organs, but it does not directly assess immune function.
While certain immune conditions may involve abdominal organs (e.g., splenomegaly), percussion is not a primary method for assessing immune function.
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