A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?

"I will keep the temperature in my house cold to avoid becoming overheated."

"I will follow my prescribed medication regimen and inform my healthcare provider of any side effects."

"I will try to manage my stress levels through relaxation techniques and therapy."

"I will make sure to wear protective clothing when I go outside."

Answer and Explanation

The Correct Answer is A

A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important for individuals with SLE, maintaining an overly cold environment can also trigger symptoms, as cold temperatures can lead to vasoconstriction and Raynaud's phenomenon, which is common in SLE patients.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is an essential component of managing SLE. This indicates that the client understands the importance of medication adherence in controlling the disease.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is a known exacerbating factor for SLE. This statement reflects the client's understanding of the need to reduce stress to prevent flare-ups.
D. Wearing protective clothing when going outside is important because UV light exposure can trigger SLE exacerbations. This shows that the client is aware of the need to protect their skin from sunlight.

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Correct Answer is A

Explanation

A. Clay-colored stools are indicative of a bile duct obstruction because bile is not reaching the intestines, leading to pale or clay-colored stools.
B. Tenderness in the left upper abdomen is more commonly associated with issues such as splenic or gastric problems rather than a bile duct obstruction.
C. Ecchymosis of the extremities is not typically associated with bile duct obstruction. It might indicate other issues such as bleeding disorders.
D. Straw-colored urine is not indicative of bile duct obstruction; typically, the urine would appear darker due to elevated bilirubin levels from bile duct obstruction.

A. Open the client's airway using the jaw-thrust maneuver to provide oxygenation B. Check the client's cranial nerve function by assessing pupils equal, round, reactive to light, and accommodation (PERRLA) C. Place the client in a rigid cervical collar D. Evaluate the client for brain injury

Correct Answer is A

Explanation

A. The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.
B. Checking cranial nerve function, including assessing pupils, is important for evaluating neurological status but is not the first action when the client is not breathing. Ensuring the airway is open and providing oxygenation is the priority.
C. While placing the client in a rigid cervical collar is important for stabilizing the spine and preventing further injury, it should be done after ensuring the airway is clear. The immediate concern is to address the client's non-breathing status.
D. Evaluating the client for brain injury is important for overall assessment but is secondary to addressing the immediate life threat of not breathing. Ensuring the airway is open and then stabilizing the spine is the priority.

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A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?

Nursing Test Bank

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