A nurse is planning care for a client who was recently admitted to the medical-surgical unit.
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 []
Potential condition:
The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.
The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.
Action to take:
In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.
Parameters to monitor:
To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While hospice care may be appropriate for the client, it does not directly address the client's reported depression.
B. Discussing advance directives is important for end-of-life care planning, but it may not address the client's current emotional needs.
C. Offering spiritual support acknowledges the client's emotional distress and provides an opportunity for comfort and guidance that aligns with the client's values and beliefs.
D. Offering medication without further assessment or exploration of the client's feelings may not be the most therapeutic response to the reported depression.
Correct Answer is ["C","D","F"]
Explanation
A. This statement is incorrect because tuberculosis treatment typically lasts longer than a week, and the client may remain contagious until the infectiousness subsides, which usually occurs after a few weeks of treatment.
B. TB treatment typically lasts for 6 months, not 6 weeks.
C. Rifampin, one of the medications for tuberculosis, can cause red-orange discoloration of body fluids (including tears, saliva, and urine), and can typically discolor contact lenses.
D. Directly observed therapy (DOT) is a recommended strategy for tuberculosis treatment to ensure medication adherence. Having someone observe the client taking their medication helps to confirm compliance and reduces the risk of non- adherence.
E. This statement is incorrect because alcohol consumption can interact with some tuberculosis medications, leading to potential liver toxicity or reducing the effectiveness of the drugs.
F. This statement demonstrates an understanding of the importance of informing the healthcare provider about any new medications. It's crucial to avoid potential interactions between tuberculosis medications and other drugs.
G. The Mantoux test is typically not repeated during tuberculosis treatment unless there is a specific clinical indication, such as an initial negative test with ongoing symptoms or exposure.
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