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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While the bandage may provide some support to the surgical site, its primary purpose is not to keep sutures from loosening.
B. The bandage does not directly prevent wound infection; its main role is to manage edema and provide compression. Infection prevention is achieved through sterile technique and wound care.
C. The bandage does not prevent the client from seeing the surgical site; in fact, it is typically used for compression and edema management.
D. The primary purpose of the elastic bandage is to control swelling (edema) and promote proper shaping of the residual limb. This helps prevent complications and prepares the limb for prosthetic fitting.
Correct Answer is B
Explanation
A. Loss of peripheral vision is associated with impairment of the optic nerve (cranial nerve II), not the vestibulocochlear nerve. The vestibulocochlear nerve is responsible for hearing and balance, not vision.
B. Disequilibrium with movement is a classic sign of impaired function of the vestibulocochlear nerve (cranial nerve VIII). This nerve has two branches: the cochlear branch (responsible for hearing) and the vestibular branch (responsible for balance). Damage to the vestibular branch can cause dizziness, vertigo, and difficulty maintaining balance.
C. Inability to smell is associated with impairment of the olfactory nerve (cranial nerve I), not the vestibulocochlear nerve.
D. Deviation of the tongue from midline is typically seen with impairment of the hypoglossal nerve (cranial nerve XII), not the vestibulocochlear nerve.
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