A nurse is assessing a patient who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?
Presence of peripheral edema.
Joint pain in hands and knees.
Dry, raised rash on the face.
Patient reports feelings of depression.
The Correct Answer is A
The correct answer is Choice A
Choice A rationale: Peripheral edema in a patient with systemic lupus erythematosus may indicate lupus nephritis, a serious complication involving immune complex deposition in the glomeruli. This leads to proteinuria, hypoalbuminemia, and fluid retention. Normal serum albumin ranges from 3.5–5.0 g/dL; levels below this promote third spacing and edema. Kidney involvement is a major cause of morbidity and mortality in SLE. Early detection is critical to prevent progression to renal failure, making this the highest priority finding.
Choice B rationale: Joint pain is a common manifestation of SLE due to inflammatory synovitis. It typically affects small joints symmetrically and is non-erosive. While it contributes to morbidity, it is not life-threatening and does not indicate organ damage. Inflammatory markers like ESR and CRP may be elevated, but they do not correlate with disease severity. Pain management and anti-inflammatory therapy are important, but joint pain alone does not warrant urgent provider notification compared to renal signs.
Choice C rationale: The classic malar rash in SLE is dry, raised, and erythematous, often sparing the nasolabial folds. It reflects cutaneous involvement and photosensitivity due to autoantibody-mediated inflammation. While it aids diagnosis, it is not an acute threat to organ function. Skin lesions may be managed with topical corticosteroids and sun protection. Dermatologic findings are common but not emergent unless associated with systemic symptoms like fever, vasculitis, or bullous eruptions. Thus, it is not the priority.
Choice D rationale: Depression is a significant concern in chronic autoimmune diseases due to psychosocial stress, fatigue, and neuropsychiatric lupus. However, unless accompanied by suicidal ideation or psychosis, it is not the most urgent issue. Neuropsychiatric lupus may present with seizures, psychosis, or cognitive dysfunction, which require immediate attention. Feelings of depression should be addressed through mental health support and screening, but they do not surpass the urgency of renal involvement indicated by peripheral edema
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Decreasing fluid intake can lead to dehydration and constipation, which would further impede peristalsis rather than promote it. Adequate hydration is essential for maintaining bowel regularity and facilitating the movement of intestinal contents.
Choice B rationale
Offering the bedpan every 2 hours does not directly stimulate peristalsis. While it provides an opportunity for bowel elimination, it does not address the underlying issue of decreased intestinal motility associated with paralytic ileus.
Choice C rationale
Increasing protein intake does not directly promote peristalsis. While protein is important for overall healing, it does not have a significant impact on stimulating bowel motility. Fiber intake is more directly related to promoting bowel function.
Choice D rationale
Increased ambulation stimulates peristalsis by promoting intestinal motility. Physical activity helps to move gas and fluids through the intestines, reducing the risk of paralytic ileus, which is a functional obstruction of the bowel often occurring after surgery.
Correct Answer is B
Explanation
Choice A rationale
Limiting fluid intake to 1L each day is generally not recommended for individuals with irritable bowel syndrome (IBS) unless specifically indicated due to other co-existing conditions. Adequate hydration is important for overall health and can help prevent constipation, a common symptom of IBS. General recommendations for fluid intake are around 2-3 liters per day, depending on individual needs and activity levels.
Choice B rationale
Keeping a food diary is a valuable strategy for individuals with irritable bowel syndrome (IBS) to identify specific food triggers that exacerbate their symptoms such as abdominal pain, bloating, diarrhea, or constipation. By meticulously recording food intake and associated symptoms, patients can often discern patterns and work with healthcare providers to develop an individualized dietary management plan.
Choice C rationale
Planning three moderate to large meals per day might not be suitable for all individuals with irritable bowel syndrome (IBS). Some people with IBS find that smaller, more frequent meals are better tolerated as large meals can distend the bowel and trigger symptoms. Individual responses to meal size and frequency can vary significantly.
Choice D rationale
While fiber is generally beneficial for bowel regularity, a blanket recommendation of 12 to 20g of fiber daily might not be appropriate for all individuals with irritable bowel syndrome (IBS). For some individuals, particularly those with diarrhea-predominant IBS, increasing fiber intake too quickly or consuming certain types of high-fiber foods can worsen their symptoms. Fiber intake should be individualized and often increased gradually.
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