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A nurse in a provider's office is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale:

The client exhibits hallmark symptoms of Systemic Lupus Erythematosus (SLE), including a butterfly rash on the cheeks, alopecia, joint tenderness, and elevated ANA and ESR levels. These findings, combined with anemia and thrombocytopenia, are consistent with SLE, an autoimmune disorder characterized by systemic inflammation and tissue damage.

Multiple sclerosis is primarily a neurological condition and does not align with the client’s dermatological and hematological findings. Celiac disease is associated with gastrointestinal symptoms and gluten sensitivity, which the client denies. Type 1 diabetes mellitus involves hyperglycemia and insulin deficiency, which are not relevant to the presented symptoms.

Helping the client identify aggravating factors (e.g., sunlight exposure, stress) is crucial for managing SLE. Recommending low-impact exercises can help maintain joint mobility and reduce inflammation.

Monitoring adherence to corticosteroid therapy is essential since these medications are often used to control inflammation in SLE. Assessing for depression related to body image is important due to the physical manifestations of SLE, such as alopecia and hyperpigmentation, which may affect the client’s mental health.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

Rationale

Interpretation of Assessment Findings:

  • Urine ketones:
    • DKA
      The presence of urine ketones is a hallmark of diabetic ketoacidosis (DKA), as it indicates the body is breaking down fat for energy due to insufficient insulin. Ketones are typically not present in hyperglycemic-hyperosmolar state (HHS).
  • Blood glucose greater than expected reference range:
    • DKA
    • HHS
      Elevated blood glucose levels are consistent with both DKA and HHS. However, blood glucose levels tend to be higher in HHS than in DKA, often exceeding 600 mg/dL in HHS.
  • Skin turgor:
    • DKA
    • HHS
      Decreased skin turgor indicates dehydration, which is a common feature in both DKA and HHS due to osmotic diuresis caused by hyperglycemia.
  • Creatinine greater than expected reference range:
    • DKA
    • HHS
      Elevated creatinine reflects impaired renal function, often due to dehydration or acute kidney injury, which can occur in both DKA and HHS.
  • Blood pH:
    • DKA
      A blood pH of 7.30 indicates metabolic acidosis, a defining feature of DKA. Blood pH is typically normal in HHS because it does not involve significant ketoacidosis.

Correct Answer is B

Explanation

A. While monitoring the client's temperature is important, it is not the highest priority immediately following sedation.

B. The gag reflex is a critical assessment after moderate sedation, especially following procedures like endoscopy, as it ensures that the client can protect their airway and swallow safely. If the gag reflex is not intact, there is a risk of aspiration or airway obstruction.

C. Warmth of extremities is an important sign of circulation, but it is not as critical as the gag reflex after a procedure involving sedation and airway manipulation.

D. Level of pain is important, but it is secondary to ensuring that the client’s airway is protected. Pain management can be addressed once the client's airway and safety are ensured.

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