The nurse is assessing a patient who has been admitted with an exacerbation of systemic lupus erythematosus (SLE). Which patient findings are the nurse's priority to address?

Joint swelling, tenderness, and pain with movement.

Red ulcers on the buccal mucosa.

Malar and discoid rashes.

Dark, foamy urine.

Answer and Explanation

The Correct Answer is D

Choice A reason: Joint swelling, tenderness, and pain with movement are common symptoms of systemic lupus erythematosus (SLE) but are not immediately life-threatening. They should be managed but are not the priority in this case.

Choice B reason: Red ulcers on the buccal mucosa are a concerning finding in SLE and can indicate active disease, but they are not the priority compared to signs of potential kidney involvement.

Choice C reason: Malar and discoid rashes are typical

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Correct Answer is C

Explanation

Choice A reason: Implementing a fluid restriction could worsen constipation and bowel function in patients with multiple sclerosis.

Choice B reason: Providing a bland, low-residue diet is less effective in managing bowel function compared to establishing a regular bowel routine.

Choice C reason: Establishing a bowel routine with daily stool softeners helps maintain regular bowel movements and prevents constipation, which is important for patients with multiple sclerosis.

Choice D reason: Consulting a surgeon for colostomy creation is a more invasive intervention that is not the first line of treatment for changes in bowel function in multiple sclerosis patients.

A. Normal blood pressure, deep respirations B. Increased alertness, normal heart rhythm C. High urine specific gravity, normal temperature D. Blood glucose of 250 mg/dL, disorientation

Correct Answer is B

Explanation

Choice A reason:

Normal blood pressure may indicate improved hydration, but deep respirations (often seen in metabolic acidosis or DKA) suggest that the patient is still experiencing distress. This combination does not reliably signal effective treatment for HHS.

Choice B reason:

Increased alertness shows that the patient’s mental status is improving, reflecting better cerebral perfusion and hydration.
A normal heart rhythm indicates that potassium levels are stable (thanks to the potassium chloride in the IV fluids) and that the insulin therapy is not causing dangerous shifts.
Together, these findings are the best indicators that the treatment is effective.

Choice C reason:

A high urine specific gravity reveals that the urine is still concentrated, which means dehydration persists.
Although the temperature is normal, the continued dehydration is not consistent with effective treatment of HHS.

Choice D reason:

A blood glucose of 250 mg/dL suggests that hyperglycemia is being corrected; however, persistent disorientation indicates that the patient’s mental status has not improved, meaning that the treatment has not fully resolved the critical aspects of HHS.

Thus, Choice B (Increased alertness, normal heart rhythm) is the best indicator of effective treatment.

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The nurse is assessing a patient who has been admitted with an exacerbation of systemic lupus erythematosus (SLE). Which patient findings are the nurse's priority to address?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with multiple sclerosis (MS) who is experiencing changes to their bowel function. What intervention will the nurse implement for this patient?

Correct Answer is C

Explanation

The nurse is caring for a patient with hyperosmolar hyperglycemic syndrome. The patient is receiving intravenous fluids of normal saline with 20 mEq of potassium chloride and a continuous insulin infusion. Which finding will indicate to the nurse that the treatment is effective?

Correct Answer is B

Explanation

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