Nokea
A client is experiencing symptoms that are suspected to be related to systemic lupus erythematosus. What cutaneous symptom occurs in about 50% of clients affected by this disease?
- A. Diffuse purplish lesions on the trunk
- B. Butterfly-shaped rash on the face over the bridge of the nose and cheeks
- C. Fluid-filled vesicles clustered on the cheeks, chin, and forehead
- D. Pustules scattered on the chest and back
Correct Answer: B
Rationale: A prominent sign for about half of the clients with SLE is a red, butterfly-shaped rash known as malar rash, on the face over the bridge of the nose and the cheeks. The word lupus means 'wolf.' The term may have been used as a description for the facial rash that, to some, resembled the mask of reddish-brown fur on a wolf. The other choices are not routinely seen with SLE.
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A client has had several diagnostic tests to determine systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis?
- A. Positive Anti-dsDNA antibody test
- B. Positive Anti-Sm antibodies
- C. Positive ANA titer
- D. Elevated ESR
Correct Answer: A
Rationale: Anti-double-stranded DNA (anti-dsDNA) antibody test is a test that shows high titers of antibodies against native DNA. This is very specific for SLE because this test is not positive for other autoimmune disorders. Anti-Smith (anti-Sm) antibodies are specific for SLE, but are found in only 20% to 30% of clients with SLE. ANA titer shows the presence of an autoimmune disease but is not specific to SLE. The other lab studies may also indicate multisystem involvement.
A client with degenerative joint disease asks the nurse for suggestions to avoid unusual stress on the joints. Which suggestion would be appropriate?
- A. Keep shifting weight from one foot to the other.
- B. Perform aerobic exercises.
- C. Maintain complete bed rest.
- D. Maintain good posture.
Correct Answer: D
Rationale: The nurse needs to remind the client with degenerative joint disease to maintain good posture to avoid unusual stress on a joint. Although the client need not maintain complete bed rest, performing aerobic exercises is not advisable because it may place undue stress on the joint worsening the condition. Shifting weight from one foot to the other does not help avoid unusual stress on a joint.
A client is suspected to have Lyme disease and has a red macule at the site of the tick bite with a bull's-eye rash with round rings surrounding the center. In addition, the client has a severe headache with neck stiffness. What stage of Lyme disease does the nurse suspect?
- A. Early stage 1
- B. Mid-stage
- C. Later stage
- D. Latent stage
Correct Answer: A
Rationale: Early stage 1 symptoms for about one third of clients include a red macule or papule at the site of the tick bite, a characteristic bull's-eye rash (called erythema migrans) with round rings surrounding the center, severe headache, and neck stiffness. Mid-stage and later stage symptoms include more systemic involvement like joint pain or neurological symptoms, while the latent stage may be asymptomatic.
In osteoporosis, which of the following is the most common complication?
- A. Diabetes
- B. Hypertension
- C. Compression fractures of the vertebrae
- D. Cardiac disease
Correct Answer: C
Rationale: In osteoporosis, loss of bone substance exceeds bone formation. The total bone mass and density is reduced, resulting in bones that become progressively porous, brittle, and fragile. Compression fractures of the vertebrae are common. Diabetes, hypertension, and cardiac disease may occur in response to the aging process but are not the result of osteoporosis.
A client suffered a significant ankle fracture several months ago. Which indicator would the nurse use to determine that the client is exhibiting signs and symptoms of chronic osteomyelitis?
- A. High fever
- B. Persistent draining sinus
- C. Rapid pulse
- D. Tenderness over the affected area
Correct Answer: B
Rationale: Persistent draining sinus indicates a chronic infection in a client with osteomyelitis. This is the symptom the nurse would use to differentiate between an acute and chronic infection. High fever, rapid pulse, and tenderness or pain over the affected area is evidence of an acute infection.