A patient has recently been diagnosed with systemic lupus erythematosus and is discussing self-care strategies with the nurse. Which statement from the patient suggests a need for further review of the material?
Planning my activities will help prevent fatigue.
Rest time will have to become a priority.
I can continue to sunbathe.
I will avoid direct sunlight as much as possible.
The Correct Answer is C
Choice A rationale:
Planning activities to prevent fatigue is a valid self-care strategy for SLE patients. Fatigue is a common symptom of SLE, and it can be exacerbated by overexertion. By planning activities and pacing themselves, patients can help to manage their fatigue and conserve energy.
Fatigue management strategies include:
Prioritizing tasks and delegating when possible.
Breaking down large tasks into smaller, more manageable ones. Taking frequent rest breaks throughout the day.
Maintaining a regular sleep schedule. Engaging in moderate exercise, as tolerated.
Avoiding caffeine and alcohol, which can interfere with sleep.
Addressing any underlying health conditions that may be contributing to fatigue, such as anemia or depression.
Choice B rationale:
Prioritizing rest is another essential self-care strategy for SLE patients. Rest allows the body to conserve energy and repair itself. Patients with SLE may need more rest than healthy individuals, especially during flares.
Resting strategies include:
Getting enough sleep at night. Napping during the day, as needed.
Taking breaks from activities throughout the day.
Practicing relaxation techniques, such as deep breathing or meditation.
Choice C rationale:
Sunbathing is not recommended for SLE patients, as it can trigger flares. Ultraviolet (UV) radiation from the sun can damage skin cells and exacerbate inflammation in SLE patients. This can lead to a flare-up of symptoms, such as skin rash, joint pain, and fatigue.
Sun protection strategies include:
Avoiding direct sunlight, especially during the middle of the day when UV rays are strongest. Wearing protective clothing, such as long-sleeved shirts, pants, and wide-brimmed hats.
Using sunscreen with an SPF of 30 or higher on a daily basis.
Applying sunscreen liberally and reapplying it every two hours, or more often if sweating or swimming.
Choice D rationale:
Avoiding direct sunlight is a correct self-care strategy for SLE patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administering an antipyretic would lower the client's fever, but it would not address the underlying cause of the sepsis. Antipyretics can mask important signs and symptoms of infection, making it more difficult to diagnose and treat the sepsis. It's important to identify the causative organism of sepsis to initiate appropriate antibiotic therapy.
Therefore, obtaining cultures to identify the causative organism is the priority action.
Choice B rationale:
Obtaining specified cultures is the most important action for a client with possible sepsis because it allows for the identification of the causative organism.
This information is essential for selecting the appropriate antibiotic therapy. Cultures should be obtained as soon as possible, before antibiotics are administered.
Choice C rationale:
While administering antibiotics is an important part of the treatment for sepsis, it is not the first action that the nurse should take.
Antibiotics should be administered after the causative organism has been identified.
Administering antibiotics before cultures are obtained can make it more difficult to identify the causative organism.
Choice D rationale:
Placing the client in isolation is important to prevent the spread of infection, but it is not the first action that the nurse should take.
The priority is to identify the causative organism and initiate appropriate treatment. The client can be placed in isolation after cultures have been obtained.
Correct Answer is A
Explanation
Choice A rationale:
Hyperventilation is a condition characterized by rapid and deep breathing, leading to excessive removal of carbon dioxide (CO2) from the body. This decrease in CO2 levels actually causes respiratory alkalosis, not respiratory acidosis.
CO2 is a weak acid, and its removal from the blood raises the blood pH, making it more alkaline. Key mechanisms involved in hyperventilation-induced respiratory alkalosis:
Increased alveolar ventilation: Hyperventilation increases the rate at which CO2 is expelled from the lungs, reducing its concentration in the blood.
Shift in the equilibrium of the carbonic acid-bicarbonate buffer system: The reduction in CO2 levels drives the equilibrium towards the formation of bicarbonate ions, further reducing the concentration of hydrogen ions and increasing pH.
Renal compensation: The kidneys respond to respiratory alkalosis by excreting more bicarbonate ions, which helps to normalize the blood pH.
Choice B rationale:
Asthma is a chronic respiratory disease characterized by inflammation and narrowing of the airways. This can lead to impaired ventilation and retention of CO2, which can contribute to respiratory acidosis.
Mechanisms by which asthma can cause respiratory acidosis:
Bronchoconstriction: Narrowed airways impede airflow, making it difficult to expel CO2 from the lungs.
Air trapping: Inflammation and mucus production can lead to air becoming trapped in the lungs, further increasing CO2 levels.
Hypoventilation: Severe asthma attacks can cause respiratory muscle fatigue, leading to a decrease in breathing rate and inadequate CO2 removal.
Choice C rationale:
Chronic obstructive pulmonary disease (COPD) is a group of lung diseases characterized by chronic obstruction of airflow. This obstruction can lead to impaired ventilation and retention of CO2, which can contribute to respiratory acidosis.
Mechanisms by which COPD can cause respiratory acidosis:
Emphysema: Destruction of lung tissue reduces the surface area available for gas exchange, making it difficult to expel CO2. Chronic bronchitis: Inflammation and mucus production in the airways can obstruct airflow and trap CO2 in the lungs.
Hypoventilation: COPD can lead to respiratory muscle fatigue and a decrease in breathing rate, further impairing CO2 removal.
Choice D rationale:
Pulmonary embolism (PE) is a blockage of an artery in the lungs, usually by a blood clot. This can lead to impaired gas exchange and a decrease in oxygen levels in the blood. In severe cases, PE can also cause respiratory acidosis due to inadequate CO2 removal.
Mechanisms by which PE can cause respiratory acidosis:
Ventilation-perfusion mismatch: PE obstructs blood flow to a portion of the lungs, reducing the amount of CO2 that can be removed from those areas.
Hypoxemia: Low oxygen levels in the blood can stimulate the respiratory drive, leading to hyperventilation and CO2 retention.
Right heart failure: PE can strain the right side of the heart, leading to decreased pulmonary blood flow and impaired CO2 removal.
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