A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
Pitting edema of the hands and fingers
Grey colored, non-purpuric papular rash
Dry, red rash across the bridge of the nose and on the cheeks
Subcutaneous nodules on the ulnar side of the arm
The Correct Answer is C
Choice A rationale:
Pitting edema of the hands and fingers is not a typical finding in SLE. It can occur in some cases, but it is more commonly associated with other conditions such as kidney disease or heart failure.
Choice B rationale:
Grey colored, non-purpuric papular rash is not a characteristic of SLE. This type of rash is more commonly seen in conditions such as lichen planus or sarcoidosis.
Choice C rationale:
A dry, red rash across the bridge of the nose and on the cheeks, also known as a malar rash, is a classic sign of SLE. It is often described as a "butterfly rash" because of its shape. The rash is caused by inflammation of the small blood vessels in the skin. It is typically worsened by sun exposure.
Choice D rationale:
Subcutaneous nodules on the ulnar side of the arm are a characteristic finding in rheumatoid arthritis, not SLE.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Pain management: Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes pain, stiffness, swelling, and fatigue in the joints. Pain is often the most debilitating symptom of RA, and it can significantly impact a person's quality of life.
Therefore, the nurse's primary consideration is to ensure the client's comfort by effectively managing their pain. This may involve using a variety of interventions, such as:
Administering pain medications as prescribed Applying heat or cold therapy
Using assistive devices to reduce joint strain
Teaching the client about pain management techniques, such as relaxation exercises and pacing activities
Promoting rest and sleep: Rest and sleep are essential for healing and reducing inflammation. The nurse can encourage the client to rest during the day and to get enough sleep at night.
Creating a comfortable environment: The nurse can help to create a comfortable environment for the client by adjusting the room temperature, providing soft bedding and pillows, and reducing noise and distractions.
Providing emotional support: RA can be a challenging disease to live with, and it can take a toll on a person's emotional well- being. The nurse can provide emotional support by listening to the client's concerns, offering reassurance, and encouraging them to express their feelings.
Choice B rationale:
Motivation is important: While motivation is important for self-management of RA, it is not the primary consideration for the nurse. The nurse's focus is on providing comfort and addressing the client's immediate needs. Once the client's pain and other symptoms are managed, the nurse can then work with the client to develop a plan for managing their RA long-term. This may include providing education about the disease, teaching self-care strategies, and encouraging the client to participate in activities that promote physical and emotional well-being.
Choice C rationale:
Surgery may be an option: Surgery may be an option for some clients with RA, but it is not the primary consideration for the nurse. Surgery is typically considered only after other treatment options have failed to control the client's symptoms.
Choice D rationale:
Education is important: Education is an important part of managing RA, but it is not the primary consideration for the nurse. The nurse's focus is on providing comfort and addressing the client's immediate needs. Once the client's pain and other symptoms are managed, the nurse can then provide education about the disease and its management.
Correct Answer is A
Explanation
Choice A rationale:
Protecting the airway is the highest priority during a tonic-clonic seizure. Tonic-clonic seizures involve intense muscle contractions, which can lead to biting the tongue, aspiration of secretions, or even respiratory arrest if the airway is obstructed. Turning the client's head to the side helps to maintain a clear airway and prevent these complications.
It is essential to act quickly to prevent injury and ensure adequate oxygenation. Delaying airway management could have serious consequences.
Choice B rationale:
Checking motor strength is not a priority during the active phase of a seizure. It is more important to focus on protecting the airway and preventing injury.
Motor strength can be assessed after the seizure has subsided.
Choice C rationale:
Loosening clothing around the waist may be helpful to promote comfort and breathing, but it is not the first priority. It is more important to address the airway and prevent aspiration.
Choice D rationale:
Documenting the time the seizure began is important for accurate record-keeping and assessment of seizure patterns, but it is not the first priority in the immediate management of the seizure. Documentation can be done after the client's airway and safety are ensured.
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