A nurse in a provider's office is caring for a client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale:
The client exhibits hallmark symptoms of Systemic Lupus Erythematosus (SLE), including a butterfly rash on the cheeks, alopecia, joint tenderness, and elevated ANA and ESR levels. These findings, combined with anemia and thrombocytopenia, are consistent with SLE, an autoimmune disorder characterized by systemic inflammation and tissue damage.
Multiple sclerosis is primarily a neurological condition and does not align with the client’s dermatological and hematological findings. Celiac disease is associated with gastrointestinal symptoms and gluten sensitivity, which the client denies. Type 1 diabetes mellitus involves hyperglycemia and insulin deficiency, which are not relevant to the presented symptoms.
Helping the client identify aggravating factors (e.g., sunlight exposure, stress) is crucial for managing SLE. Recommending low-impact exercises can help maintain joint mobility and reduce inflammation.
Monitoring adherence to corticosteroid therapy is essential since these medications are often used to control inflammation in SLE. Assessing for depression related to body image is important due to the physical manifestations of SLE, such as alopecia and hyperpigmentation, which may affect the client’s mental health.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encouraging the client to urinate every 2 hr is not appropriate in this situation because the client is receiving continuous bladder irrigation (CBI), and the urinary catheter is meant to drain continuously. The issue is likely related to a blockage or clot in the catheter, not the need for the client to urinate.
B. Securing the urinary catheter to the upper left quadrant is not appropriate because the catheter should be positioned properly to allow for proper drainage. Securing it in an inappropriate location could cause kinks or obstructions.
C. Using 0.9% sodium chloride to perform an intermittent bladder irrigation is the correct action. The client’s scant amount of fluid and bladder spasms suggest that the catheter may be blocked, likely by a clot. Performing an intermittent irrigation with saline can help clear any obstructions in the catheter and restore proper drainage.
D. Applying a cold compress to the suprapubic area is not appropriate for treating bladder spasms caused by a potential obstruction. The priority action is to clear the catheter and ensure proper drainage.
Correct Answer is D
Explanation
A. While checking the client’s vital signs is important, it is not the first action the nurse should take. The priority is to stop the transfusion immediately to prevent further harm.
B. Administering oxygen may be necessary if the client’s condition worsens, but stopping the transfusion is the first step in addressing the potential transfusion reaction.
C. Collecting a urine sample may be important if hemolysis is suspected, but the first priority is to stop the transfusion to prevent further damage.
D. The symptoms of chills, back pain, and nausea are indicative of a potential transfusion reaction, such as hemolytic reaction. The nurse’s first action is to stop the transfusion to prevent further complications. After stopping the infusion, the nurse should notify the provider, monitor the client’s vital signs, and assess for additional symptoms.
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