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: Delaying ambulation until the next day is not an appropriate intervention, as it can cause stiffness, muscle weakness, or joint contractures in the affected knee. The nurse should encourage regular exercise and activity within the client's tolerance level to maintain joint mobility and function.
Choice B reason: Applying moist heat prior to ambulation is an appropriate intervention, as it can reduce pain and inflammation in the affected knee by increasing blood flow and relaxing the muscles and tendons around the joint.
Choice C reason: Using a continuous passive motion machine is not an appropriate intervention for osteoarthritis, as it is mainly used after knee replacement surgery to prevent scar tissue formation and improve range of motion in the new joint.
Choice D reason: Restricting intake of dairy products is not an appropriate intervention for osteoarthritis, as dairy products are good sources of calcium and vitamin D that can support bone health and prevent osteoporosis. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, lean protein, and low-fat dairy products.
Correct Answer is A
Explanation
Choice A reason: Using analgesia around the clock is an appropriate action. The nurse should follow the principle of prevention rather than rescue when managing pain for a client who has terminal cancer. The nurse should administer analgesics on a regular schedule to maintain a steady level of pain relief and prevent breakthrough pain.
Choice B reason: Applying pain patches each morning and removing them at bedtime is not an appropriate action. The nurse should follow the manufacturer's instructions for applying and removing pain patches. Some patches are designed to be worn for 24 hours, while others are worn for 72 hours. Removing the patches too soon can cause inadequate pain control and withdrawal symptoms.
Choice C reason: Using intramuscular medications to control pain is not an appropriate action. The nurse should avoid using intramuscular route for administering analgesics to a client who has terminal cancer. Intramuscular injections are painful, unreliable, and increase the risk of infection and bleeding. The nurse should use oral, transdermal, or subcutaneous routes whenever possible.
Choice D reason: Decreasing a medication dose if the client develops tolerance is not an appropriate action. The nurse should understand that tolerance is a normal physiological response to long-term opioid use and does not indicate addiction or abuse. The nurse should adjust the medication dose according to the client's level of pain and response to treatment.
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