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 C

Explanation

Choice A reason: White milky liquid stools immediately after a barium enema are not uncommon and are typically due to the passage of barium. This finding does not usually require immediate reporting unless there are other concerning symptoms.

Choice B reason: Not having a bowel movement for three days in a patient with irritable bowel syndrome (IBS) can be uncomfortable but is not typically an emergency. Management can be addressed through dietary and medication adjustments rather than immediate reporting.

Choice C reason: A temperature of 101°F and abdominal distention in a patient diagnosed with ulcerative colitis is concerning and should be reported immediately. These symptoms can indicate a serious complication such as toxic megacolon, perforation, or severe infection, which require prompt medical intervention.

Choice D reason: A blood glucose level of 225 mg/dL in a patient receiving Total Parenteral Nutrition (TPN) is elevated but not necessarily an emergency. Elevated blood glucose levels are a common side effect of TPN and can be managed through adjustments in insulin or TPN composition.

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?

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Naxlex Comprehensive Predictor Exams

The nurse is in the G unit is assessing a patient after receiving the change of shift SBAR report. What assessment findings will the nurse report immediately to the provider?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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