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 C
Explanation
Choice A reason: Purulent exudate is a thick, yellowgreen, or brown pus that indicates infection. It is not bloodtinged and does not drip from the wound.
Choice B reason: Serous exudate is a clear, thin, and watery fluid that is normal in the inflammatory stage of wound healing. It does not contain blood cells and is not red in color.
Choice C reason: Serosanguineous exudate is a pink or red fluid that contains both serum and blood. It is common in the proliferative stage of wound healing and may drip from the wound due to increased capillary permeability.
Choice D reason: Sanguineous exudate is a bright or dark red fluid that consists mostly of blood. It indicates active bleeding and is usually seen in traumatic or surgical wounds. It is not diluted with serum and is more viscous than serosanguineous exudate.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Increased agitation is a nonverbal sign of pain, because it indicates that the client is restless, uncomfortable, or distressed by the pain. Agitation can manifest as fidgeting, tossing, turning, moaning, or groaning.
Choice B reason: Decreased attention span is not a nonverbal sign of pain, but rather a cognitive or behavioral sign of pain. Decreased attention span means that the client has difficulty focusing, concentrating, or remembering things, which can be affected by pain. However, decreased attention span is not a direct expression of pain, but rather a consequence of pain.
Choice C reason: Grimacing is a nonverbal sign of pain, because it indicates that the client is experiencing facial muscle tension, contraction, or distortion due to the pain. Grimacing can manifest as frowning, wrinkling the forehead, pursing the lips, or clenching the teeth.
Choice D reason: Reported pain of 5/10 is not a nonverbal sign of pain, but rather a verbal sign of pain. Reported pain of 5/10 means that the client has communicated the intensity of their pain using a numerical scale, which is a subjective and selfreported measure of pain. However, reported pain of 5/10 is not a direct expression of pain, but rather a description of pain.
Choice E reason: Increase in heart rate is a nonverbal sign of pain, because it indicates that the client is experiencing physiological changes due to the pain. Increase in heart rate can manifest as tachycardia, palpitations, or arrhythmias.
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