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A nurse in a provider's office is caring for a client.

Exhibits

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.

Answer and Explanation

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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Related Questions

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale

  1. The client weighs 88 kg, and the prescription is to administer 15 mL/kg in the first hour: 88 x 15= 1320mL
  2. The prescription then reduces the rate to 10 mL/kg per hour: 88 x 10= 880mL

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

Rationale

Interpretation of Actions:

  • Encourage the client to cough:
    • Nonessential
      Encouraging the client to cough is not a priority in this situation. The client's neurological status is deteriorating, and the focus should be on managing intracranial pressure and ensuring airway patency rather than promoting coughing.
  • Initiate seizure precautions:
    • Anticipated
      Seizure precautions are appropriate due to the client's declining neurological status, as seizures can occur with increased intracranial pressure or other neurological changes.
  • Elevate the head of the bed:
    • Anticipated
      Elevating the head of the bed to 30 degrees promotes venous drainage and helps reduce intracranial pressure, which is critical given the client's symptoms.
  • Keep the client's head in a midline position:
    • Anticipated
      Maintaining a midline head position prevents obstruction of venous outflow and helps reduce intracranial pressure.
  • Decrease oxygen to 1.5 L/min via nasal cannula:
    • Contraindicated
      Reducing oxygen is inappropriate in this situation. The client's altered mental status and vomiting suggest potential hypoxia or increased intracranial pressure, requiring close monitoring of oxygenation rather than decreasing it.
  • Assist the client to the bathroom:
    • Contraindicated
      Assisting the client to the bathroom is unsafe due to their altered mental status, restlessness, and risk of falls or further neurological compromise. Instead, measures to prevent overexertion, such as using a bedpan, should be implemented.

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