A nurse is planning care for a client who was recently admitted to the medical-surgical unit.
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.
The Correct Answer is []
Potential condition:
The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.
The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.
Action to take:
In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.
Parameters to monitor:
To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
- A Mantoux test: This is used to detect tuberculosis (TB) infection, especially if there's a suspicion of TB based on symptoms or exposure history.
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A chest x-ray: This imaging test helps assess for lung conditions, including pneumonia, tuberculosis, or other pulmonary issues that might be causing the client's symptoms.
Incorrect Choices and Explanations:
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A nasopharyngeal swab: This is used for detecting respiratory viruses, such as influenza or COVID-19, rather than evaluating TB or general lung conditions.
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A pulmonary function test: This measures lung function and is used to diagnose conditions like asthma or chronic obstructive pulmonary disease (COPD), which might not be the immediate concern in an emergency setting without specific symptoms.
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Blood cultures: These are used to identify bacterial infections in the bloodstream rather than evaluating TB or assessing lung conditions.
Correct Answer is B
Explanation
A. Limiting intake of dairy products may not directly address stomatitis unless the client has an intolerance or allergy to dairy.
B. Using a soft-bristle toothbrush helps prevent trauma to the oral mucosa, which can exacerbate stomatitis. Gentle oral care with a soft toothbrush after meals helps maintain oral hygiene without causing further irritation.
C. Moistening lips with lemon-glycerin swabs may further irritate the oral mucosa due to the acidic nature of lemon.
D. Gargling with an alcohol-based mouthwash can exacerbate stomatitis and should be avoided due to its drying effect on oral tissues.
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