A nurse is planning care for a client who was recently admitted to the medical-surgical unit.

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 []

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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Correct Answer is C

Explanation

A. Placing a newborn in a forward-facing car seat is unsafe and not recommended due to the risk of injury in case of a crash.
B. Turning the baby's car seat around at 15 pounds is too early. Rear-facing car seats are recommended until the child reaches the weight or height limit set by the manufacturer.
C. Positioning the baby at a 45-degree angle in the car seat helps prevent airway obstruction and allows for proper breathing and spinal alignment.
D. Placing a baby in the front seat, even with the airbag turned off, is not recommended due to the risk of injury from airbag deployment.

A. "Your child can return to school once the lesions have crusted over." B. "Your child can return to school once the fever has subsided." C. "Your child can return to school 24 hours after beginning antibiotics." D. "Your child can return to school after a negative titer result."

Correct Answer is A

Explanation

A: Varicella (chickenpox) is contagious until all lesions have crusted over. The crusting of the lesions indicates that the virus is no longer active and transmissible.
B: Although a decrease in fever suggests improvement, it does not signify that the child is no longer contagious. Children with varicella are still contagious until all blisters have crusted over.
C: Antibiotics are not effective against viral infections like varicella. Therefore, this statement is inaccurate as it implies antibiotics are part of the treatment for varicella.
D: Varicella is diagnosed clinically and through symptoms rather than titer results. Titer testing is not a standard criterion for determining when a child can return to school.

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

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