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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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Related Questions

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.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

Conditions:

  1. Placental abruption, the premature separation of the placenta from the uterine wall, can occur due to hypertension, which increases the risk of vascular damage and bleeding behind the placenta, leading to its separation.
  2. Oligohydramnios, a condition characterized by a deficiency of amniotic fluid, is typically associated with decreased fetal urine production, renal abnormalities, or placental insufficiency. However, none of the findings listed in the scenario directly correlate with this condition.
  3. Spontaneous abortion, also known as miscarriage, can occur due to various factors such as genetic abnormalities, hormonal imbalances, or maternal health conditions. However, none of the findings listed in the scenario directly correlate with this condition.
  4. Chorioamnionitis is an infection of the fetal membranes and amniotic fluid. While maternal fever is often associated with chorioamnionitis, it is not a finding listed in the scenario. Additionally, the other findings do not directly correlate with this condition.
  5. Placenta previa is a condition where the placenta partially or completely covers the cervix. This condition is not directly associated with the findings listed in the scenario.

Findings:

  1. Hypertension is a risk factor for placental abruption due to increased vascular resistance, which can lead to vascular damage and placental separation.
  2. Temperature elevation may indicate an infection, such as chorioamnionitis, which can increase the risk of placental abruption.
  3. Hyperreflexia can be associated with conditions like preeclampsia, which is characterized by hypertension and can increase the risk of placental abruption.
  4. Vomiting alone is not directly associated with an increased risk of placental abruption.
  5. Fundal height measurement can provide information about fetal growth and gestational age but is not directly associated with an increased risk of placental abruption.

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