The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?

Choice A reason: The client having a butterfly rash is not a concerning finding in a client with SLE. A butterfly rash is a malar rash that appears across the cheeks and the bridge of the nose. It is a common sign of SLE and may flare up or fade depending on the disease activity. It does not indicate any serious complication or organ damage.

Choice B reason: A blood pressure of 126/85 mm Hg is not a concerning finding in a client with SLE. This blood pressure is within the normal range and does not indicate hypertension or hypotension. Hypertension is a possible complication of SLE that may affect the kidneys, the heart, or the brain. Hypotension may indicate shock, dehydration, or infection.

Choice C reason: The client reporting chronic fatigue is not a concerning finding in a client with SLE. Chronic fatigue is a common symptom of SLE that affects the quality of life and the ability to perform daily activities. It may be caused by inflammation, pain, anemia, depression, or medication side effects. It does not indicate any acute or lifethreatening condition.

Choice D reason: A urine output of 20 mL/hour is a concerning finding in a client with SLE. This urine output is below the normal range of 30 to 50 mL/hour and indicates oliguria, which is a reduced urine production. Oliguria may indicate acute kidney injury, which is a serious complication of SLE that may lead to renal failure or death. The nurse should monitor the client's urine output, fluid balance, electrolytes, and kidney function and report any abnormal findings to the provider.

Choice A reason: Popping bursae from standing is not the cause of the grating sound. Bursae are fluidfilled sacs that cushion the joints and reduce friction. Popping bursae may produce a snapping or clicking sound, but not a grating sound.

Choice B reason: A herniated disk in the diseased joint is not the cause of the grating sound. A herniated disk is a condition where the soft inner part of the intervertebral disk bulges out through a tear in the outer layer. A herniated disk may cause pain, numbness, or weakness, but not a grating sound.

Choice C reason: Pieces of bone and cartilage floating is the cause of the grating sound. Osteoarthritis is a degenerative joint disease that causes the breakdown of the cartilage and bone in the joints. Pieces of bone and cartilage may detach and float in the joint space, causing a grating sound when the joint moves.

Choice D reason: Years of an autoimmune process is not the cause of the grating sound. An autoimmune process is a condition where the immune system attacks the body's own tissues. An autoimmune process may cause inflammation, swelling, or damage to the joints, but not a grating sound.