A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

Choice A reason: Joint pain with swelling is the correct answer, because it is a common symptom of SLE. SLE is a chronic autoimmune disease that causes inflammation and damage to various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Joint pain with swelling is caused by the inflammation of the synovial membrane that lines the joints, which can lead to stiffness, reduced mobility, and deformity.

Choice B reason: Intense wrinkles is not the correct answer, because it is not a symptom of SLE. Intense wrinkles are a cosmetic issue that affects the appearance of the skin, not the function of the organs or tissues. Intense wrinkles are caused by the loss of collagen and elasticity in the skin, which can result from aging, sun exposure, smoking, or dehydration.

Choice C reason: Raynaud's phenomenon is not the correct answer, because it is not a symptom of SLE. Raynaud's phenomenon is a condition that affects the blood flow to the fingers and toes, not the joints or other organs. Raynaud's phenomenon is caused by the narrowing of the small arteries that supply blood to the extremities, which can result from cold, stress, or other factors.

Choice D reason: Tachycardia is not the correct answer, because it is not a symptom of SLE. Tachycardia is a condition that affects the heart rate, not the joints or other organs. Tachycardia is caused by the abnormal electrical activity of the heart, which can result from anxiety, fever, infection, or other causes.

Choice A reason: A bone fragment has injured the nerve supply in the area is not the best response by the nurse. This may be a possible complication of a fracture, but it does not explain the mechanism of compartment syndrome. Compartment syndrome is a condition where the pressure within a closed space (such as a muscle compartment) exceeds the perfusion pressure and causes ischemia and necrosis of the tissues. A bone fragment may damage the nerve, but it does not cause increased pressure in the compartment.

Choice B reason: An injured artery causes impaired arterial perfusion through the compartment is not the best response by the nurse. This may be a possible cause of compartment syndrome, but it is not the most common one. Compartment syndrome is more often caused by venous obstruction than arterial obstruction. An injured artery may reduce the blood flow to the compartment, but it does not cause increased pressure in the compartment.

Choice C reason: Bleeding and swelling cause increased pressure in an area that cannot expand is the best response by the nurse. This is the most common cause of compartment syndrome and explains the pathophysiology of the condition. Bleeding and swelling are the result of inflammation and tissue injury that occur after a fracture. They increase the volume of fluid in the compartment, which cannot expand due to the rigid fascia that surrounds it. This leads to increased pressure in the compartment, which compresses the blood vessels, nerves, and muscles and causes ischemia and necrosis of the tissues.

Choice D reason: The fascia expands with injury, causing pressure on underlying nerves and muscles is not the best response by the nurse. This is not a correct statement, as the fascia does not expand with injury. The fascia is a tough connective tissue that encloses the muscle compartments and limits their expansion. The fascia is part of the problem, not the cause, of compartment syndrome. The fascia prevents the compartment from accommodating the increased volume of fluid and causes increased pressure in the compartment.