A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

Joint pain.

Hematuria.

Low grade fever.

Muscle atrophy.

Answer and Explanation

The Correct Answer is B

Choice A reason: Joint pain is a common symptom of SLE, which is an autoimmune disease that causes inflammation and damage to various organs and tissues. Joint pain can be managed with anti-inflammatory drugs, analgesics, and corticosteroids. Joint pain is not a life-threatening finding that requires immediate attention from the health care provider.

Choice B reason: Hematuria is the presence of blood in the urine, which can indicate kidney damage or failure. Kidney involvement is one of the most serious complications of SLE, which can lead to end-stage renal disease and require dialysis or transplantation. Hematuria is a critical finding that requires prompt intervention and treatment from the health care provider.

Choice C reason: Low grade fever is another common symptom of SLE, which can be caused by infection, inflammation, or medication side effects. Low grade fever can be treated with antipyretics, fluids, and antibiotics if needed. Low grade fever is not a life-threatening finding that requires immediate attention from the health care provider.

Choice D reason: Muscle atrophy is the loss of muscle mass and strength, which can occur due to inactivity, malnutrition, or steroid use. Muscle atrophy can be prevented or reversed with exercise, nutrition, and physiotherapy. Muscle atrophy is not a life-threatening finding that requires immediate attention from the health care provider.

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Correct Answer is B

Explanation

Choice A reason: Overall fluid intake should not be limited, but rather increased, for a client with urinary tract calculi. Increasing fluid intake can help flush out the stones and prevent new ones from forming.

Choice B reason: Tea and hot chocolate should be limited, because they contain oxalates, which can increase the risk of calcium oxalate stones, the most common type of urinary tract calculi. Other foods high in oxalates include spinach, rhubarb, nuts, and chocolate.

Choice C reason: Low-sodium soups are not a problem for a client with urinary tract calculi, unless they have other conditions that require sodium restriction, such as hypertension or heart failure. Sodium intake does not directly affect the formation of stones, but it can increase calcium excretion in the urine, which can contribute to calcium oxalate stones.

Choice D reason: Citrus fruit juices are beneficial for a client with urinary tract calculi, because they contain citrate, which can prevent the crystallization of calcium and oxalate in the urine. Citrate can also help dissolve existing stones and prevent new ones from forming.

A. Confirmation of the autoimmune disease process. B. Evidence of spread of the disease to the kidneys. C. Indication of the onset of joint degeneration. D. Representative of a decline in the client’s condition.

Correct Answer is A

Explanation

Choice A reason: Rheumatoid factor is an antibody that is produced by the immune system and can bind to normal tissues, causing inflammation and damage. Rheumatoid factor is a marker of the autoimmune disease process that underlies rheumatoid arthritis, which is a chronic condition that affects the joints and other organs. A high level of rheumatoid factor can confirm the diagnosis of rheumatoid arthritis and indicate the severity of the disease.

Choice B reason: Rheumatoid factor is not a specific indicator of kidney involvement in rheumatoid arthritis, which is a rare but possible complication of the disease. Kidney damage can occur due to inflammation of the blood vessels, medication side effects, or dehydration. Kidney function can be assessed by other laboratory tests, such as blood urea nitrogen, creatinine, and urine analysis.

Choice C reason: Rheumatoid factor is not a direct cause of joint degeneration in rheumatoid arthritis, which is a progressive condition that leads to joint deformity and disability. Joint degeneration can occur due to chronic inflammation, erosion of cartilage and bone, and formation of nodules and cysts. Joint damage can be evaluated by physical examination, x-rays, and magnetic resonance imaging.

Choice D reason: Rheumatoid factor is not a reliable predictor of the client’s condition in rheumatoid arthritis, which is a variable and unpredictable disease that can have periods of remission and exacerbation. The client’s condition can be influenced by many factors, such as age, gender, genetics, lifestyle, and treatment. The client’s condition can be monitored by clinical symptoms, functional status, and quality of life.

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A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?

Correct Answer is B

Explanation

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

Correct Answer is A

Explanation

A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?

A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?

The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?