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What is a priority nursing intervention for a client with lupus who is receiving steroids for a flareup?
The nurse washes their hands before entering the room.
Assist with the enhancement of social wellbeing by providing activities.
Assessing the client’s support system.
Ensure privacy by keeping the door always closed.
The Correct Answer is A
Choice A reason: This is the priority nursing intervention because it helps to prevent infection, which is a major complication and risk factor for mortality in clients with lupus. Lupus is an autoimmune disease that causes inflammation and damage to various organs and tissues. Steroids are used to reduce inflammation and suppress the immune system, but they also increase the susceptibility to infection. The nurse should wash their hands before and after contact with the client and follow standard precautions to reduce the transmission of microorganisms.
Choice B reason: This is not the priority nursing intervention, but it is a good intervention to promote the psychosocial health of the client. Lupus can affect the client's selfesteem, mood, and social relationships, especially during a flareup, which is a period of increased symptoms and activity of the disease. The nurse should assist with the enhancement of social wellbeing by providing activities that are appropriate for the client's physical and mental condition, such as reading, listening to music, or talking with friends and family.
Choice C reason: This is not the priority nursing intervention, but it is a good intervention to evaluate the client's coping and support resources. Lupus can be a chronic and unpredictable disease that can cause stress, anxiety, and depression in the client. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide emotional, practical, and financial assistance to the client. The nurse should also refer the client to counseling, support groups, or other services as needed.
Choice D reason: This is not the priority nursing intervention, but it is a good intervention to respect the client's dignity and autonomy. Lupus can affect the client's appearance, mobility, and independence, which can make them feel vulnerable and embarrassed. The nurse should ensure privacy by keeping the door always closed, unless the client requests otherwise, and by knocking and asking for permission before entering the room. The nurse should also cover the client with a blanket or gown and expose only the necessary body parts during assessment or procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: Padding hard surfaces is a nursing intervention that decreases the risk of pressure injuries, because it reduces the pressure, shear, and friction on the skin and underlying tissues. Hard surfaces, such as bed rails, wheelchair arms, or footrests, can cause compression or irritation of the skin, especially over the bony prominences. Padding hard surfaces with foam, gel, or air cushions can provide protection and comfort for the client.
Choice B reason: Keeping head of bed (HOB) at or less than 30 degrees is a nursing intervention that decreases the risk of pressure injuries, because it prevents the sliding or shifting of the client in bed. Sliding or shifting can cause shear and friction on the skin, especially over the sacrum, coccyx, or heels. Keeping head of bed (HOB) at or less than 30 degrees can maintain the alignment and stability of the client in bed.
Choice C reason: Keeping head of bed (HOB) elevated to 75 degrees is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Elevating the head of bed (HOB) to 75 degrees can cause the client to slide or shift in bed, which can increase the shear and friction on the skin, as explained above. Elevating the head of bed (HOB) to 75 degrees can also increase the pressure on the sacrum, coccyx, or heels, which can impair the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Having client sit in wheelchair as much as possible is not a nursing intervention that decreases the risk of pressure injuries, but rather one that increases the risk of pressure injuries. Sitting in wheelchair as much as possible can cause prolonged pressure, shear, and friction on the skin and underlying tissues, especially over the ischial tuberosities, sacrum, coccyx, or heels. Sitting in wheelchair as much as possible can also reduce the mobility and activity of the client, which can affect the blood circulation and muscle tone.
Choice E reason: Placing pillows between bony surfaces is a nursing intervention that decreases the risk of pressure injuries, because it relieves the pressure, shear, and friction on the skin and underlying tissues. Bony surfaces, such as the ankles, knees, hips, or elbows, can cause compression or irritation of the skin, especially when they are in contact with each other or with the bed. Placing pillows between bony surfaces can provide cushioning and separation for the skin and tissues.
Correct Answer is A
Explanation
Choice A reason: Inflammatory is the phase of wound healing that occurs at the time of injury and lasts about 35 days, because it is the first and immediate response to tissue damage. Inflammatory is the phase of wound healing that involves the activation of the immune system, the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of a clot. Inflammatory is the phase of wound healing that aims to control bleeding, prevent infection, and prepare the wound for healing.
Choice B reason: Proliferative is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the inflammatory phase and lasts about 23 weeks. Proliferative is the phase of wound healing that involves the growth and multiplication of new cells, the formation of granulation tissue, the synthesis of collagen, the contraction of the wound edges, and the development of epithelial tissue. Proliferative is the phase of wound healing that aims to fill the wound, restore the strength, and cover the defect.
Choice C reason: Maturation is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the proliferative phase and lasts about several months to years. Maturation is the phase of wound healing that involves the remodeling and reorganization of the collagen fibers, the reduction of scar tissue, the improvement of elasticity, and the restoration of function. Maturation is the phase of wound healing that aims to refine the wound, enhance the quality, and optimize the outcome.
Choice D reason: Intentional is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather a classification of wound healing that depends on the type and extent of tissue damage, the degree of contamination, and the method of closure. Intentional is a classification of wound healing that refers to wounds that are surgically created, have minimal tissue loss, are clean and sterile, and are closed by primary intention, which means that the wound edges are approximated with sutures, staples, or glue. Intentional is a classification of wound healing that results in faster healing, less scarring, and lower risk of infection.
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