What is a classic symptom assessed in clients with lupus?

Choice A reason: Send the client back to surgery is not the nurse's next action, because it is premature and inappropriate. Sending the client back to surgery requires a medical order and a clear indication of the need for surgical intervention. The nurse cannot make this decision without first assessing the wound and contacting the provider.

Choice B reason: Call the provider immediately is not the nurse's next action, because it is not the most urgent and relevant. Calling the provider immediately is an important action, but it should be done after assessing the wound and gathering the necessary data. The nurse should be able to report the findings of the wound assessment, such as the size, shape, color, amount, and type of drainage, as well as the vital signs, pain level, and mental status of the client.

Choice C reason: Assess the wound for signs of dehiscence is the nurse's next action, because it is the most urgent and relevant. Assessing the wound for signs of dehiscence is a priority action, because it can identify the cause and severity of the problem. Dehiscence is a complication that occurs when the surgical incision splits open or separates, which can cause increased drainage, pain, and infection. Dehiscence can be caused by factors such as infection, poor wound healing, excessive strain, or trauma. Dehiscence can be detected by inspecting the wound for gaps, edges, or protrusions.

Choice D reason: Prepare to culture the wound is not the nurse's next action, because it is not the most urgent and relevant. Preparing to culture the wound is a possible action, but it should be done after assessing the wound and contacting the provider. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound requires a medical order and a sterile technique.

Choice A reason: This is the best intervention because it helps the nurse to understand the client's emotional, social, and practical needs and resources. A new diagnosis of HIV can be a devastating and overwhelming experience for the client, who may face stigma, discrimination, isolation, or rejection from others. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide comfort, guidance, and assistance to the client. The nurse should also encourage the client to seek professional counseling, peer support, or other services as needed.

Choice B reason: This is not the best intervention because it may not respect the client's preferences, beliefs, or values. The nurse should not assume that the client wants or needs spiritual or religious support, unless the client expresses such a desire. The nurse should ask the client about their spiritual or religious beliefs and practices and provide appropriate referrals or resources as requested by the client. The nurse should also respect the client's right to privacy and confidentiality and not disclose the client's diagnosis to anyone without the client's consent.

Choice C reason: This is not the best intervention because it may not be the most urgent or appropriate topic to discuss with the client at this time. The nurse should not focus on the legal or ethical aspects of the client's diagnosis, but rather on the client's emotional and physical wellbeing. The nurse should explain the legal requirement to tell sex partners in a sensitive and respectful manner, but only after the client has accepted and understood their diagnosis and has expressed readiness to disclose their status to others. The nurse should also provide the client with information and resources on how to prevent the transmission of HIV and how to protect themselves and their partners.

Choice D reason: This is not the best intervention because it may not be the client's wish or choice. The nurse should not offer to tell the family for the client, unless the client asks for such help. The nurse should respect the client's autonomy and decisionmaking regarding whom to tell and when to tell about their diagnosis. The nurse should also support the client in preparing for the possible reactions and outcomes of disclosing their status to their family and others.