What nursing intervention is appropriate for a client with systemic lupus erythematosus (SLE)?
Administer topical hydrocortisone
Apply cold therapy to the extremities
Administer antibiotics
Encourage ultraviolet (UV) light exposure
The Correct Answer is A
Choice A reason: Administering topical hydrocortisone is the appropriate nursing intervention, because it can help reduce the inflammation and itching of the skin lesions that are common in SLE. SLE is a chronic autoimmune disease that causes the immune system to attack various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Hydrocortisone is a type of corticosteroid that can suppress the immune response and relieve the symptoms of SLE.
Choice B reason: Applying cold therapy to the extremities is not the appropriate nursing intervention, because it can worsen the circulation and sensation of the fingers and toes that are affected by Raynaud's phenomenon, which is a complication of SLE. Raynaud's phenomenon is a condition that causes the blood vessels in the extremities to narrow and spasm in response to cold or stress, resulting in numbness, pain, and color changes. Cold therapy can trigger or aggravate Raynaud's phenomenon.
Choice C reason: Administering antibiotics is not the appropriate nursing intervention, because it is not indicated for SLE, unless there is a secondary infection. SLE is not caused by bacteria, but by the abnormal activity of the immune system. Antibiotics are drugs that can kill or inhibit the growth of bacteria, but they have no effect on the underlying cause of SLE. Antibiotics can also have side effects, such as allergic reactions, gastrointestinal disturbances, or resistance.
Choice D reason: Encouraging ultraviolet (UV) light exposure is not the appropriate nursing intervention, because it can trigger or worsen the skin lesions and the disease activity of SLE. UV light is a type of radiation that can damage the DNA and the cells of the skin, causing inflammation, redness, and blistering. UV light can also stimulate the production of antibodies and cytokines that can attack the organs and tissues of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A client with leukemia is a susceptible host most at risk for infection. Leukemia is a type of cancer that affects the blood cells, especially the white blood cells, which are responsible for fighting infections. Leukemia causes the production of abnormal and immature white blood cells that cannot function properly and crowd out the normal ones. This leads to a condition called leukopenia, which is a low level of white blood cells. Leukopenia makes the client more vulnerable to infection by reducing the immune system's ability to defend against pathogens.
Choice B reason: A child who is immunized is not a susceptible host most at risk for infection. Immunization is a process that stimulates the immune system to produce antibodies against a specific disease. Immunization protects the child from getting infected by the disease or reduces the severity of the infection if it occurs. Immunization also prevents the spread of the disease to other people who are not immunized or who are immunocompromised.
Choice C reason: A 60yearold client is not a susceptible host most at risk for infection. Age is a factor that may influence the susceptibility to infection, but it is not the most important one. Older adults may have a weaker immune system due to aging, chronic diseases, or medications, but they may also have a stronger immune memory due to previous exposure to pathogens. The risk of infection in older adults depends on their overall health status, lifestyle, and preventive measures.
Choice D reason: A hospitalized 35yearold client is not a susceptible host most at risk for infection. Hospitalization is a factor that may increase the exposure to infection, but it is not the most significant one. Hospitalized clients may encounter various sources of infection, such as health care workers, other clients, medical equipment, or invasive procedures, but they may also receive adequate infection control measures, such as hand hygiene, isolation, sterilization, or prophylaxis. The risk of infection in hospitalized clients depends on their diagnosis, treatment, and compliance.
Correct Answer is A
Explanation
Choice A reason: Inspecting the client's skin is the nurse's priority, because it is the most urgent and relevant action. Inspecting the client's skin can help identify any signs of infection, injury, or infestation, such as wounds, rashes, ulcers, or lice. The client's skin may be compromised by the lack of hygiene, exposure to the elements, or poor nutrition. The client's skin may also be a source of transmission of pathogens to other clients or staff. Therefore, inspecting the client's skin is essential for the assessment, diagnosis, and treatment of the client's condition.
Choice B reason: Providing a towel and showing the client to the shower is not the nurse's priority, because it is not the most urgent and relevant action. Providing a towel and showing the client to the shower is an important intervention, but it should be done after inspecting the client's skin and ensuring the safety and infection prevention of the client and others. The client may have wounds, rashes, or ulcers that need to be cleaned, dressed, or treated before bathing. The client may also have lice or scabies that need to be isolated and treated with special shampoos or creams before bathing. The client may also need assistance or supervision during bathing, depending on the client's physical and mental status.
Choice C reason: Asking if the client has been to a homeless shelter recently is not the nurse's priority, because it is not the most urgent and relevant action. Asking if the client has been to a homeless shelter recently is an important question, but it should be done after inspecting the client's skin and providing a towel and showing the client to the shower. The client's history of homelessness and shelter use may provide some information about the client's social and environmental factors, such as exposure to violence, abuse, or disease, or access to resources, services, or support. However, this information is not as critical as the client's skin condition, which may require immediate attention and care.
Choice D reason: Calling a social worker is not the nurse's priority, because it is not the most urgent and relevant action. Calling a social worker is an important referral, but it should be done after inspecting the client's skin, providing a towel and showing the client to the shower, and asking if the client has been to a homeless shelter recently. The social worker can help the client with the psychosocial and practical aspects of homelessness, such as finding a shelter, applying for benefits, accessing health care, or addressing mental health or substance abuse issues. However, this referral is not as urgent as the client's skin condition, which may require immediate attention and care.
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