A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?

"I will use an astringent on my face."

"I will cleanse my skin using an antibacterial soap."

"I will dry my skin by patting it with a towel."

"I will limit my time in the tanning bed to 15 minutes."

Answer and Explanation

The Correct Answer is C

Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect the skin. Proper skin care is important for individuals with SLE to minimize potential flare-ups or exacerbation of skin symptoms. The recommended approach to skin care in SLE includes gentle cleansing and moisturizing.

"I will use an astringent on my face." Astringents are typically not recommended for individuals with SLE as they can be harsh on the skin and may cause irritation or dryness.

"I will cleanse my skin using an antibacterial soap." While it is important to keep the skin clean, using an antibacterial soap is not specifically required for individuals with SLE. Gentle,

Non-irritating cleansers without antibacterial properties are generally recommended.

"I will limit my time in the tanning bed to 15 minutes." Exposure to ultraviolet (UV) radiation, such as from tanning beds, can be particularly harmful to individuals with SLE. UV radiation can trigger or worsen skin manifestations and may lead to disease flares. Therefore, it is generally advised for individuals with SLE to avoid tanning beds altogether.

In addition to gentle cleansing and moisturizing, individuals with SLE should also practice sun protection, including wearing sunscreen with a high sun protection factor (SPF) and using protective clothing and accessories (such as hats and sunglasses) when exposed to the sun. Regular check-ups with a healthcare provider and following their recommendations are important for managing SLE and its associated skin manifestations.

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Correct Answer is D

Explanation

Are you thinking of hurting yourself?

When a client expresses thoughts of self-harm or suggests that others would be better off without them, it is essential for the nurse to assess for suicidal ideation and ensure the client's safety. Asking directly about thoughts of self-harm is an appropriate and crucial response in this situation.

When you get better you will not feel this way in (option A) is incorrect. This response minimizes the client's feelings and does not address the seriousness of the situation. It is important to assess the client's immediate safety before discussing long-term improvement.

Why would you think a thing like that? In (option B) is incorrect. This response may come across as judgmental or dismissive of the client's feelings. It is essential to provide a supportive and non- judgmental environment for the client to express their thoughts and concerns.

What would your family do without you? In (option C) is incorrect This response also minimizes the client's feelings and does not address the underlying issue. It is crucial to focus on the client's immediate safety and well-being rather than shifting the focus to the impact on others.

A. Release the client's restraints every 4 hr. B. Check the client's status every hour. C. Document the client's behavior leading to the initiation of the restraints. D. Obtain written consent from the client for the placement of the restraints.

Correct Answer is C

Explanation

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release.

Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

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A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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