A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?
Wash your hair with a mild protein shampoo.
Apply powder liberally to sensitive skin areas.
Use a sun blocking agent with a sun protection factor of at least 15.
Avoid using moisturizing lotions on your skin.
None
None
The Correct Answer is C
Choice A reason: This is incorrect. While gentle hair care is important, it is not as critical as sun protection for SLE patients.
Choice B reason: This is incorrect. Powder can be drying, and SLE patients often need to keep their skin moisturized.
Choice C reason: This is correct. SLE patients are often photosensitive and need to protect their skin from UV rays.
Choice D reason: This is incorrect. SLE patients should keep their skin well moisturized to prevent dryness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Sleepy, but arousing when the name is called
Feeling sleepy after receiving morphine is a common side effect. However, the fact that the client can be aroused when their name is called suggests that this is not necessarily an adverse effect.
The nurse should continue monitoring the client but may not consider this as a significant adverse reaction.
Choice B: Pain level of 6 on a scale from 0 to 10
Pain relief is one of the intended effects of morphine. Therefore, experiencing pain reduction is not an adverse effect.
The nurse would likely view this as a positive response to the medication.
Choice C: Respiratory rate of 8/min
A respiratory rate of 8 breaths per minute is significantly low and indicates respiratory depression, which is a serious adverse effect of morphine.
The nurse should be concerned about this finding and take appropriate action.
Choice D: SaO2 94%
An oxygen saturation (SaO2) level of 94% is within the normal range (usually 95% or higher). It is unlikely to be directly related to morphine administration.
While this value is not concerning, the nurse should continue monitoring the client's oxygen saturation.
Correct Answer is A
Explanation
Choice A reason: Right lower quadrant.
McBurney's point is located in the right lower quadrant of the abdomen, which is one-third of the distance from the anterior superior iliac spine to the umbilicus. This is the area where tenderness is most likely to be maximal in cases of acute appendicitis.
Choice B reason: Left lower quadrant
The left lower quadrant is not typically associated with appendicitis pain, as the appendix is located in the right lower quadrant of the abdomen.
Choice C reason: Right upper quadrant
The right upper quadrant is generally associated with other conditions such as gallbladder issues, not appendicitis.
Choice D reason: The left upper quadrant
The left upper quadrant is also not associated with appendicitis pain, as it is on the opposite side of the typical location of the appendix.
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