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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Correct Answer is A

Explanation

A. A low pressure alarm on the ventilator often indicates a leak in the system, which can be due to a cuff leak in the endotracheal tube or tracheostomy. The nurse should evaluate for a cuff leak or other issues that may be causing the air to escape.

B. While water in the ventilator tubing can cause a high pressure alarm, it is less likely to trigger a low pressure alarm. Emptying the water from the tubing may be necessary but is not the first priority in this situation.

C. Increasing the ventilator flow rate is not an appropriate response to a low pressure alarm. The problem is likely a leak, and addressing the leak is more important than adjusting the flow rate.

D. Suctioning the client's airway may be necessary if the client has secretions that are obstructing the airway, but it is not the first intervention for a low pressure alarm. The primary concern should be checking for a leak or disconnection.

A. Productive cough B. Spontaneous bruising C. Hematemesis D. Ascites E. Increased albumin level F. Elevated iron

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

Explanation

Rationale

Interpretation of Findings:

Productive cough:
- Unrelated to diagnosis
  A productive cough is not directly related to cirrhosis. It may indicate a respiratory issue, but it does not directly reflect the progression or improvement of the client's liver condition.
Spontaneous bruising:
- Indication of potential worsening condition
  Spontaneous bruising suggests a decline in clotting function, which is common in advanced cirrhosis due to impaired liver synthesis of clotting factors.
Hematemesis:
- Indication of potential worsening condition
  Hematemesis indicates gastrointestinal bleeding, which could result from esophageal varices or other complications of portal hypertension, a severe complication of cirrhosis.
Ascites:
- Indication of potential worsening condition
  Ascites reflects worsening fluid retention and portal hypertension, indicating the progression of cirrhosis.
Increased albumin level:
- Indication of potential improvement
  An increased albumin level suggests improved liver synthetic function or nutritional status, which is a positive sign in a client with cirrhosis.
Elevated iron:
- Unrelated to diagnosis
  Elevated iron levels are associated with the client's history of hemochromatosis but are not directly indicative of the progression or improvement of cirrhosis in this context.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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

Explanation

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