This is the edited text:
What is a priority nursing intervention for a client with lupus who is receiving steroids for a flareup?
The nurse washes their hands before entering the room.
Assist with the enhancement of social wellbeing by providing activities.
Assessing the client’s support system.
Ensure privacy by keeping the door always closed.
The Correct Answer is A
Choice A reason: This is the priority nursing intervention because it helps to prevent infection, which is a major complication and risk factor for mortality in clients with lupus. Lupus is an autoimmune disease that causes inflammation and damage to various organs and tissues. Steroids are used to reduce inflammation and suppress the immune system, but they also increase the susceptibility to infection. The nurse should wash their hands before and after contact with the client and follow standard precautions to reduce the transmission of microorganisms.
Choice B reason: This is not the priority nursing intervention, but it is a good intervention to promote the psychosocial health of the client. Lupus can affect the client's selfesteem, mood, and social relationships, especially during a flareup, which is a period of increased symptoms and activity of the disease. The nurse should assist with the enhancement of social wellbeing by providing activities that are appropriate for the client's physical and mental condition, such as reading, listening to music, or talking with friends and family.
Choice C reason: This is not the priority nursing intervention, but it is a good intervention to evaluate the client's coping and support resources. Lupus can be a chronic and unpredictable disease that can cause stress, anxiety, and depression in the client. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide emotional, practical, and financial assistance to the client. The nurse should also refer the client to counseling, support groups, or other services as needed.
Choice D reason: This is not the priority nursing intervention, but it is a good intervention to respect the client's dignity and autonomy. Lupus can affect the client's appearance, mobility, and independence, which can make them feel vulnerable and embarrassed. The nurse should ensure privacy by keeping the door always closed, unless the client requests otherwise, and by knocking and asking for permission before entering the room. The nurse should also cover the client with a blanket or gown and expose only the necessary body parts during assessment or procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the highest priority client because a urinary tract infection (UTI) is a common and treatable condition that affects the lower urinary system, such as the bladder or urethra. A fever of 38.5°C and flank pain can indicate that the infection has spread to the upper urinary system, such as the kidneys, which can cause pyelonephritis. Pyelonephritis is a serious but not lifethreatening complication that requires antibiotic therapy and hydration. The nurse should monitor the client's vital signs, urine output, and pain level and administer the prescribed medication and fluids.
Choice B reason: This is not the highest priority client because a deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the lower extremities. A positive Homans' sign and edema in the affected leg can indicate that the clot is causing inflammation and obstruction of the blood flow. DVT is a serious but not lifethreatening complication that requires anticoagulant therapy and compression therapy. The nurse should monitor the client's vital signs, leg circumference, and pain level and administer the prescribed medication and stockings.
Choice C reason: This is the highest priority client because a myocardial infarction (MI) is a heart attack that occurs when the blood flow to a part of the heart muscle is blocked, causing tissue damage or death. Chest pain and shortness of breath can indicate that the client is experiencing acute cardiac ischemia, which can lead to cardiac arrest or heart failure. MI is a lifethreatening emergency that requires immediate intervention and treatment. The nurse should activate the rapid response team, monitor the client's vital signs, electrocardiogram, and oxygen saturation, and administer the prescribed medication and oxygen.
Choice D reason: This is not the highest priority client because a stroke is a brain attack that occurs when the blood flow to a part of the brain is interrupted, causing tissue damage or death. Slurred speech and facial droop can indicate that the client is experiencing acute neurological impairment, which can affect their communication and facial expression. Stroke is a serious but not lifethreatening complication that requires prompt evaluation and treatment. The nurse should monitor the client's vital signs, neurological status, and glucose level and administer the prescribed medication and fluids.
Correct Answer is A
Explanation
Choice A reason: This is the correct statement because it reflects the fact that reexposure to HIV can increase the viral load and accelerate the decline of the immune system. HIV is a virus that infects and destroys the CD4 cells, which are the white blood cells that help fight infections. AIDS is the final stage of HIV infection, when the CD4 count falls below 200 cells/mm3 or the client develops an opportunistic infection. The progression from HIV to AIDS can vary from person to person, depending on several factors, such as viral strain, genetic factors, treatment adherence, and coinfections. Reexposure to HIV can expose the client to a different or more aggressive strain of the virus, which can overwhelm the immune system and hasten the development of AIDS.
Choice B reason: This is an incorrect statement because it ignores the role of nutrition in maintaining the health and function of the immune system. Diet can influence the progression of HIV to AIDS by affecting the client's weight, energy, metabolism, and susceptibility to infections. The client should eat a balanced and varied diet that provides adequate calories, protein, vitamins, minerals, and fluids. The client should also avoid foods that can cause diarrhea, dehydration, or food poisoning, which can worsen the symptoms and complications of HIV infection.
Choice C reason: This is an incorrect statement because it contradicts the evidence that shows that meditation can have positive effects on the psychological and physiological wellbeing of people living with HIV. Meditation is a mindbody practice that involves focusing attention on the present moment, breathing, and relaxation. Meditation can help the client cope with stress, anxiety, depression, and pain, which are common challenges for people living with HIV. Meditation can also improve the immune system function by reducing inflammation, oxidative stress, and cortisol levels, which can slow down the progression of HIV to AIDS.
Choice D reason: This is an incorrect statement because it overlooks the impact of sexually transmitted infections (STIs) on the course of HIV infection. STIs can increase the risk of transmitting and acquiring HIV by causing ulcers, inflammation, or bleeding in the genital area, which can facilitate the entry and exit of the virus. STIs can also increase the viral load and decrease the CD4 count, which can speed up the progression of HIV to AIDS. The client should practice safe sex by using condoms, getting tested and treated for STIs, and informing their sexual partners about their HIV status.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.