A nurse is reinforcing skin care teaching with a client who has systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)
"I will apply an SPF 30 sunscreen before gardening."
"I should cleanse reddened areas of my face with an astringent."
"I will gently pat my skin dry after bathing."
"I should apply lotion to my skin twice daily."
Correct Answer : A,C,D
Choice A reason: Applying an SPF 30 sunscreen before gardening is an appropriate statement, as it indicates that the client understands the importance of protecting their skin from sun exposure, which can trigger or worsen lupus flare-ups and cause skin rashes or lesions.
Choice B reason: Cleansing reddened areas of their face with an astringent is not an appropriate statement, as it indicates that the client does not understand that astringents can irritate or dry out their skin and aggravate their condition. The client should use mild soap and water or moisturizing cleanser to wash their face gently.
Choice C reason: Gently patting their skin dry after bathing is an appropriate statement, as it indicates that the client understands how to avoid rubbing or scratching their skin, which can cause injury or infection and delay healing.
Choice D reason: Applying lotion to their skin twice daily is an appropriate statement, as it indicates that the client understands how to keep their skin hydrated and prevent dryness or cracking that can increase their risk of infection or inflammation.
Choice E reason: Limiting time on tanning beds to 10 minutes is not an appropriate statement, as it indicates that the client does not understand that tanning beds emit ultraviolet rays that can harm their skin and worsen their lupus symptoms. The client should avoid tanning beds altogether and wear protective clothing and sunglasses when outdoors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Keeping both arms below the level of the client's heart can increase venous pressure and fluid accumulation in the affected arm, which can lead to lymphedema.
Choice B reason: After a mastectomy, it’s important to avoid procedures like blood draws, injections, or blood pressure measurements on the side where the surgery was performed to prevent lymphedema. Therefore, using the client’s left arm for blood samples is a preventive measure.
Choice C reason: Obtaining blood pressure readings using the client's right arm is an incorrect action that can increase lymphatic fluid accumulation and impair circulation in the affected arm.
Choice D reason: Limiting range-of-motion exercises with the affected arm is an incorrect action that can decrease lymphatic drainage and increase swelling in the affected arm. The nurse should encourage the client to perform gentle exercises, such as squeezing a soft ball or raising and lowering the arm, to promote lymphatic flow and prevent stiffness.
Correct Answer is ["A","C","D"]
Explanation
a) You should shower instead of taking a tub bath. This is correct because showering reduces the risk of infection and promotes wound healing.
b) You may take aspirin for mild pain. This is incorrect because aspirin can increase the risk of bleeding and interfere with clotting. The client should take acetaminophen or another nonsteroidal anti-inflammatory drug (NSAID) for pain relief.
c) You should avoid lifting objects that weigh more than 8 pounds. This is correct because lifting heavy objects can strain the surgical site and cause bleeding or herniation.
d) You might see blood in your urine after coughing. This is correct because coughing can increase the pressure in the bladder and cause blood to leak from the urethra. This is normal and should subside within a few days.
e) You may resume sexual intercourse after 2 weeks. This is incorrect because sexual intercourse can cause trauma to the prostate and urethra and delay healing. The client should wait at least 6 weeks before resuming sexual activity.
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