The nurse is assessing a patient who has been admitted with an exacerbation of systemic lupus erythematosus (SLE). Which patient findings are the nurse's priority to address?

Joint swelling, tenderness, and pain with movement.

Red ulcers on the buccal mucosa.

Malar and discoid rashes.

Dark, foamy urine.

Answer and Explanation

The Correct Answer is D

Choice A reason: Joint swelling, tenderness, and pain with movement are common symptoms of systemic lupus erythematosus (SLE) but are not immediately life-threatening. They should be managed but are not the priority in this case.

Choice B reason: Red ulcers on the buccal mucosa are a concerning finding in SLE and can indicate active disease, but they are not the priority compared to signs of potential kidney involvement.

Choice C reason: Malar and discoid rashes are typical

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Correct Answer is D

Explanation

Choice A reason: While a post-operative patient preparing for discharge is important, they are stable enough to be considered for discharge and do not require immediate assessment.

Choice B reason: A patient with Cushing's disease after insertion of a nasogastric tube may need monitoring, but this is not as urgent as a patient with potential respiratory distress.

Choice C reason: A patient scheduled for a chest radiograph who is anxious about their treatment does not require immediate intervention compared to a patient experiencing respiratory issues.

Choice D reason: A patient with chronic obstructive pulmonary disease who requested a breathing treatment during the previous shift may be experiencing respiratory distress and requires immediate assessment and intervention to prevent further complications.

A. Remind the patient that they will be responsible for caring for the ileostomy after discharge. B. Reassure the patient that this procedure will be reversed in a few months. C. Acknowledge the patient's reluctance and initiate discussion to explore their feelings. D. Discuss with the medical team during interdisciplinary rounds the need for a psychiatric referral.

Correct Answer is C

Explanation

Choice A reason: Reminding the patient that they will be responsible for caring for the ileostomy after discharge may increase their anxiety and reluctance. It does not address the underlying concerns or feelings.

Choice B reason: Reassuring the patient that the procedure will be reversed in a few months is not always accurate and may provide false hope. Each patient's situation is unique, and not all ileostomies are temporary.

Choice C reason: Acknowledging the patient's reluctance and initiating a discussion to explore their feelings is the most appropriate response. This approach allows the nurse to understand the patient's concerns, provide emotional support, and offer practical solutions to help the patient feel more comfortable with ostomy care.

Choice D reason: Discussing the need for a psychiatric referral during interdisciplinary rounds is not the immediate step. The nurse should first address the patient's feelings and concerns directly and provide support.

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The nurse is assessing a patient who has been admitted with an exacerbation of systemic lupus erythematosus (SLE). Which patient findings are the nurse's priority to address?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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