A nurse is reviewing laboratory findings for three clients.
Which of the following laboratory results should the nurse expect for a client who has cirrhosis?

Choice A rationale:

Cleansing the skin with an antibacterial soap is not typically recommended for clients with systemic lupus erythematosus (SLE) unless there is a specific medical indication for antibacterial soap. Using mild, non-irritating, hypoallergenic soap is usually preferred to avoid skin irritation in individuals with SLE.

Choice B rationale:

This is the correct answer. Patting the skin dry with a towel instead of rubbing it helps to prevent excessive friction and irritation, which can be particularly important for individuals with SLE who may have sensitive skin. The client demonstrates an understanding of appropriate skin care by choosing this option.

Choice C rationale:

Using an astringent on the face is generally discouraged for individuals with SLE. Astringents can be harsh and may irritate the skin, which can exacerbate skin problems commonly associated with SLE. This statement indicates a misunderstanding of appropriate skin care.

Choice D rationale:

Limiting time in the tanning bed is advisable for anyone, as excessive exposure to UV radiation can increase the risk of skin damage and skin cancers. However, individuals with SLE are especially sensitive to UV radiation, and they should avoid tanning beds altogether. This statement indicates a lack of understanding of the specific needs of individuals with SLE regarding sun exposure.

The correct answer is choice B and C.

Choice A rationale:

Cervical insufficiency is a condition where the cervix begins to shorten and open too early during pregnancy, leading to premature birth or loss of an otherwise healthy pregnancy. However, the client’s symptoms do not indicate cervical insufficiency. There are no reports of lower abdominal pressure, mild pelvic cramps, or a change in vaginal discharge, which are common symptoms of cervical insufficiency.

Choice B rationale:

The client’s severe headache unrelieved by acetaminophen, +3 pitting edema in bilateral lower extremities, and hyperactive reflexes (patellar reflex 4+) are indicative of severe preeclampsia. One of the complications of severe preeclampsia is seizures, also known as eclampsia. Therefore, the client is at risk for developing seizures.

Choice C rationale:

Placental abruption is a serious pregnancy complication in which the placenta detaches from the uterus prematurely. The client’s report of decreased fetal movement could be a sign of placental abruption. In addition, severe preeclampsia can increase the risk of placental abruption. Therefore, the client is at risk for developing placental abruption.

Choice D rationale:

Heart failure occurs when the heart can’t pump enough blood to meet the body’s needs. While preeclampsia can eventually affect many organ systems including the cardiovascular system, there are no immediate signs of heart failure in the client’s symptoms.

Choice E rationale:

Hypoglycemia refers to low blood sugar levels. The client’s symptoms do not suggest hypoglycemia. Symptoms of hypoglycemia typically include confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart or irregular heartbeat, sweating, trembling or tremors, and weakness. In conclusion, based on the client’s symptoms and clinical presentation, she is at greatest risk for developing seizures (Choice B) and placental abruption (Choice C) due to severe preeclampsia.