A. This is not typical for Raynaud's phenomenon. Instead, Raynaud's is characterized by episodes of reduced blood flow to the extremities, often triggered by cold or stress, leading to sensations of coldness or numbness rather than warmth.
B. This finding aligns with Raynaud's phenomenon. During an episode, the blood vessels constrict in response to cold or stress, leading to pallor (whiteness) in the affected areas, such as the toes and fingers. This is a classic symptom of the condition.
C. While feet can become reddened due to increased blood flow after rewarming or after exposure to warmth, this is not a characteristic feature of Raynaud's phenomenon. In Raynaud's, the affected areas typically exhibit color changes from white (pallor) to blue (cyanosis) and then red (hyperemia) as blood flow returns, but redness upon ambulation is not specifically indicative of the phenomenon.
D. Swelling of the joints can occur in SLE due to arthritis or inflammation but is not a direct symptom of Raynaud's phenomenon. Raynaud's primarily affects blood flow and does not inherently cause joint swelling; however, a client with SLE may experience joint symptoms due to other underlying inflammatory processes.

A. This statement indicates some understanding of self-care, as using gentle hair products can help minimize irritation. However, it's not specifically focused on the most critical aspects of SLE management related to skin care.
B. Clients with SLE should inspect their skin regularly, not just once a month, as they are at a higher risk for rashes and skin lesions. More frequent self-assessment can help catch any changes early.
C. Clients with SLE are generally advised to avoid tanning beds altogether, as ultraviolet (UV) exposure can exacerbate skin rashes and trigger flares of the disease. Limiting exposure to UV light is essential for managing lupus.
D. Applying powder to a rash may not be advisable, as it could irritate the skin further. Clients should be taught to keep the affected areas clean and follow their healthcare provider's recommendations for treating rashes.

A. This statement is not typically related to rheumatoid arthritis. RA does not cause low blood sugar directly. While medications or other conditions might affect blood sugar levels, this is not a common symptom or concern specific to RA.
B. Morning stiffness is a hallmark symptom of rheumatoid arthritis. Patients often report increased stiffness and discomfort in their joints upon waking, which can improve with activity throughout the day.
C. While some individuals might gain weight due to reduced physical activity or medication side effects (like corticosteroids), weight loss is also common due to pain and decreased mobility. Thus, this statement is not universally applicable.
D. Abdominal pain is not a primary symptom of RA. However, certain medications used to treat RA, like nonsteroidal anti-inflammatory drugs (NSAIDs), can cause gastrointestinal discomfort, but this is not a direct result of the disease itself.

A. A positive antinuclear antibody (ANA) titer is a common finding in SLE. This test is often used as a screening tool for autoimmune diseases, and most patients with SLE will have a positive ANA. Therefore, this finding is expected.
B. The presence of protein in the urine (proteinuria) is indicative of kidney involvement, which can occur in SLE due to lupus nephritis. Given the client's difficulty urinating and other symptoms, this finding would be anticipated.
C. This statement is unlikely to be correct. In SLE, anemia is common due to various factors, including chronic disease, bone marrow involvement, or hemolysis. Therefore, an increased hemoglobin level would not be expected in this scenario.
D. This finding is not typically associated with SLE. SLE is primarily an autoimmune disease affecting the connective tissues, and thyroid function tests (like T3 and T4) would not show increased levels unless there is an underlying thyroid disorder. Therefore, this finding is not expected in SLE.
E. An elevated blood urea nitrogen (BUN) level may be anticipated, especially if there is kidney involvement due to lupus nephritis. Increased BUN can indicate impaired kidney function, which aligns with the client's symptoms of difficulty urinating.

A. This statement indicates a good understanding of nutritional needs. High-protein foods are essential for maintaining muscle mass and supporting immune function, particularly for individuals with HIV. Finger foods can also help if the client has a reduced appetite or difficulty with larger meals.
B. While hydration is important, 1 liter may not be sufficient for overall health, especially if the client is experiencing weight loss or other symptoms of dehydration. The nurse would typically recommend a higher intake, considering fluid needs can vary based on activity level and overall health.
C. This statement may not be optimal for weight gain. For someone struggling with weight maintenance, smaller, more frequent meals may be more beneficial than three large meals. Large meals might lead to fullness and decrease overall caloric intake, which can hinder weight gain efforts.
D. While fats can provide a high caloric density, a diet excessively high in unhealthy fats is not ideal. It’s important to focus on healthy fats (like avocados, nuts, and olive oil) rather than just increasing fat intake indiscriminately.

A. Weight gain is not a typical finding associated with SLE. Patients often experience weight loss due to decreased appetite, fatigue, or increased metabolism. Therefore, this choice is less likely to be expected.
B. While some patients with SLE may develop cardiac complications, such as pericarditis or valvular disease, a systolic murmur is not a common or characteristic finding of the disease itself. This choice is not specifically indicative of SLE.
C. Alopecia, or hair loss, is a common finding in patients with SLE. It can occur due to the disease itself or as a side effect of certain medications used in treatment. This choice is a typical manifestation of SLE.
D. Petechiae can occur in SLE, particularly when there is thrombocytopenia (low platelet count) or vasculitis associated with the condition. While it is not as common as alopecia, it can still be an expected finding in some cases of SLE.

A. While rinsing fruits is good practice, it may not fully eliminate the risk of pathogens, especially for someone with a compromised immune system.
B. This statement is the best indication of understanding how to prevent infections. Changing kitty litter can expose the client to Toxoplasma gondii, which is particularly risky for immunocompromised individuals. Wearing gloves is a direct and effective precaution.
C. Although wearing an N95 mask can be appropriate in certain situations, it may not be necessary for all interactions with sick family members. A standard surgical mask is often sufficient.
D. Cooking vegetables is a good practice for food safety, especially for immunocompromised individuals, but this statement is more general than specifically addressing a particular risk.

A. This term refers to the passage of fresh blood through the anus, usually indicating lower GI bleeding (such as from the colon or rectum). It is a common and significant sign of GI bleeding.
B. Hypertension (high blood pressure) is generally not a sign of GI bleeding. In fact, GI bleeding typically leads to hypotension (low blood pressure) due to volume loss, making this choice incorrect.
C. Tarry stool (melena) indicates the presence of digested blood in the stool, typically resulting from upper GI bleeding. It appears black and sticky and is a common sign of GI bleeding.
D. This refers to vomiting that looks like coffee grounds, which indicates that blood has been present in the stomach and has undergone digestion. This is a classic sign of upper GI bleeding and is a significant symptom.
E. Hematemesis is the vomiting of blood, which can be bright red or resemble coffee grounds, depending on the source and severity of the bleeding. It is a common and serious sign of GI bleeding, particularly from the upper GI tract.

A. This type of shock occurs when there is widespread vasodilation leading to a relative hypovolemia, often seen in conditions like sepsis. Given that the patient has a surgical site infection, this is a plausible consideration. However, distributive shock typically involves more than just hypotension, including symptoms like warm skin and possible fever.
B. This type of shock results from significant fluid loss, leading to inadequate circulating volume. It can occur after surgery due to bleeding or fluid loss, but the context here suggests that the primary issue is infection rather than direct fluid loss.
C. Obstructive shock happens when there is a physical obstruction to blood flow, such as in cases of pulmonary embolism or tension pneumothorax. There’s no indication of obstruction in this scenario related to the infection and hypotension.
D. This shock type occurs when the heart fails to pump effectively, often due to myocardial infarction or severe heart failure. The patient’s history does not suggest heart dysfunction, so this option is less likely.

A. Using a filtered IV line helps remove any particulate matter that could be present in the TPN solution, reducing the risk of complications such as phlebitis or embolism.
B. TPN should have its own dedicated line to prevent incompatibilities and ensure the TPN solution is delivered without interference. Infusing other medications through the same line can lead to complications and reduce the effectiveness of TPN.
C. If TPN gets stopped or runs out, a bag of 5% dextrose in water (D5W) should be hung to prevent hypoglycemia. D10% is too concentrated and can cause hyperglycemia.
D. To minimize the risk of infection and maintain sterility, TPN bags and tubing should be replaced every 24 hours. This helps prevent bacterial growth in the TPN solution.
E. TPN is typically administered through a central line because it allows for the infusion of hypertonic solutions that can irritate peripheral veins. Central lines provide better access to larger blood vessels, reducing the risk of complications.