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 A
Explanation
Choice A reason: Withholding the medication if the systolic blood pressure is less than 90 mm Hg is an appropriate action, as propranolol is a beta-blocker that can lower blood pressure and cause hypotension, which can impair tissue perfusion and cause dizziness, fainting, or shock.
Choice B reason: Requesting a dosage increase if the apical heart rate is less than 60/min is an inappropriate action, as propranolol can slow down the heart rate and cause bradycardia, which can lead to fatigue, weakness, or cardiac arrest. The nurse should monitor the apical pulse before administering propranolol and withhold it if it is less than 60/min.
Choice C reason: Informing the client to expect increased hair growth is an incorrect statement, as propranolol does not cause hypertrichosis or excessive hair growth. However, another beta-blocker, minoxidil, can cause this side effect.
Choice D reason: Administering the medication with an antacid is not an appropriate action, as antacids can interfere with the absorption of propranolol and reduce its effectiveness. The nurse should administer propranolol on an empty stomach or with food that does not contain antacids.
Correct Answer is A
Explanation
Choice A reason: Asking the client if they are having difficulty breathing is the highest priority question, as it can assess the severity of their allergic reaction to penicillin and the risk of anaphylaxis, which is a life-threatening condition that can cause airway obstruction and respiratory failure.
Choice B reason: Taking the client's heart rate is not a question, but an action that can be done after asking the client about their breathing status. The heart rate can indicate the presence of tachycardia or arrhythmia, which are signs of cardiovascular compromise due to an allergic reaction.
Choice C reason: Telling the client that they need to receive diphenhydramine is not a question, but an action that can be done after asking the client about their breathing status. Diphenhydramine is an antihistamine drug that can reduce the symptoms of an allergic reaction, such as itching, swelling, or wheezing.
Choice D reason: Asking the client if they have any allergies to medications is not a high priority question, as it can be done before administering penicillin or after stabilizing the client's condition. Knowing the client's allergy history can help prevent future adverse reactions and guide appropriate treatment choices.Question 42
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