A nurse is teaching a client who has SLE (Lupus) about self-care. Which of the following statements by the client indicates an understanding of the teaching?

"I should use a mild hair shampoo"

"I will inspect my skin once a month for rashes"

“I should limit my time in the tanning bed to 10 minutes

"I will apply powder to any skin rash"

Answer and Explanation

The Correct Answer is A

A.   This statement indicates some understanding of self-care, as using gentle hair products can help minimize irritation. However, it's not specifically focused on the most critical aspects of SLE management related to skin care.
B.   Clients with SLE should inspect their skin regularly, not just once a month, as they are at a higher risk for rashes and skin lesions. More frequent self-assessment can help catch any changes early.
C.   Clients with SLE are generally advised to avoid tanning beds altogether, as ultraviolet (UV) exposure can exacerbate skin rashes and trigger flares of the disease. Limiting exposure to UV light is essential for managing lupus.
D.   Applying powder to a rash may not be advisable, as it could irritate the skin further. Clients should be taught to keep the affected areas clean and follow their healthcare provider's recommendations for treating rashes.

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Correct Answer is ["C","D"]

Explanation

A. Premature Ventricular Contractions (PVC's) (A) are related to cardiac activity and not directly indicative of respiratory function.
B. A respiratory rate of 14 breaths per minute is within the normal range for adults (12-20 breaths per minute). Therefore, this finding does not indicate a decline in respiratory status.
C. Circumoral cyanosis, which refers to a bluish discoloration around the mouth, indicates hypoxia and is a sign of deteriorating respiratory status. It suggests that the body is not getting enough oxygen, which is critical to monitor in an asthma attack.
D. Retractions, especially of the sternal muscles, are a sign of increased work of breathing and can indicate severe respiratory distress. This finding suggests that the patient is struggling to breathe effectively, indicating a decline in respiratory status.
E. An SpO2 of 95% is generally considered acceptable, especially in patients with asthma, as normal oxygen saturation levels typically range from 95% to 100%. While it is at the lower end of normal, it does not indicate an immediate decline in respiratory status.

A. Show expected changes in white blood cell counts. B. Skin tests for tuberculosis may be falsely negative. C. Should receive influenza, pneumococcal, and shingles vaccinations. D. Higher risk for respiratory tract and genitourinary infections. E. Booster vaccinations are not likely needed as one ages. F. May not have a fever with severe infection.

Correct Answer is ["B","C","D","F"]

Explanation

A. While it's important for older adults to have regular blood tests to monitor their health, showing expected changes in white blood cell counts is not a specific risk factor for infections.
B. Skin tests for tuberculosis may be falsely negative in older adults due to a weakened immune response.
C. Older adults should stay up-to-date on their vaccinations, including influenza, pneumococcal, and shingles vaccinations, to help protect themselves against these infections.
D. Older adults are at increased risk for respiratory tract infections, such as pneumonia, and genitourinary infections, such as urinary tract infections.
E. Booster vaccinations are essential for older adults to maintain protection against diseases such as influenza, tetanus, diphtheria, and pertussis.
F. Older adults may not develop a fever in response to a severe infection. This can make it difficult to recognize the presence of an infection.

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A nurse is teaching a client who has SLE (Lupus) about self-care. Which of the following statements by the client indicates an understanding of the teaching?

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