Nokea
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 3 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The client is most likely experiencing ………………..
- A. acute coronary syndrome
- B. pneumothorax
- C. cardiac tamponade
Correct Answer: C
Rationale: Given the client's SLE history, chest pain, and lack of ST-elevations or troponin elevation, cardiac tamponade is the most likely diagnosis, as SLE can cause pericarditis leading to fluid accumulation. Acute coronary syndrome is less likely without ECG or troponin changes, and pneumothorax is not supported by the scenario.
You may also like to solve these questions
The nurse is discussing the underlying mechanism of psoriasis with a client recently diagnosed with the condition. The nurse explains that psoriasis is primarily associated with?
- A. overactivity of the immune system targeting healthy skin cells.
- B. deficiency of T lymphocytes leading to skin inflammation.
- C. impaired production of melanocytes causing skin discoloration.
- D. excessive sebum production resulting in follicular plugging.
Correct Answer: A
Rationale: Psoriasis is caused by overactivity of the immune system, particularly T cells, attacking healthy skin cells (A), leading to rapid skin turnover and plaques. T lymphocyte deficiency (B) is unrelated, melanocyte issues (C) cause pigmentation changes, and excessive sebum (D) is linked to acne.
The nurse is assessing a client who has suspected Raynaud phenomenon/disease. Which of the following findings would support a diagnosis of Raynaud phenomenon/disease?
- A. unilateral swelling of the leg
- B. painful vasospasms
- C. crepitus of the joints
- D. claudication in feet and lower extremities
Correct Answer: B
Rationale: Painful vasospasms (B) are a hallmark of Raynaud's phenomenon, caused by cold or stress-induced vasoconstriction. Unilateral leg swelling (A) suggests venous issues, crepitus (C) indicates joint pathology, and claudication (D) is related to peripheral artery disease.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 4 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client experiencing cardiac tamponade.
- A. Prepare the client for an immediate thoracentesis
- B. Obtain a prescription for an isotonic fluid bolus
- C. Perform frequent vital sign collection
- D. Obtain a prescription for intravenous furosemide
Correct Answer: C
Rationale: For cardiac tamponade, frequent vital sign collection (C) is indicated to monitor hemodynamic stability. Thoracentesis (A) is for pleural effusion, not pericardial fluid. Fluid bolus (B) may worsen tamponade by increasing pericardial pressure. Furosemide (D) is contraindicated as it reduces preload, which is already compromised.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 2 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Which of the following issues is the client at risk of developing? Select all that apply.
- A. cardiac tamponade
- B. cardiogenic shock
- C. stroke
- D. pneumothorax
- E. acute coronary syndrome
Correct Answer: A,B,C,E
Rationale: SLE increases the risk of cardiac tamponade (A) due to pericarditis, cardiogenic shock (B) from cardiac involvement, stroke (C) from antiphospholipid syndrome, and acute coronary syndrome (E) from accelerated atherosclerosis. Pneumothorax (D) is not a typical SLE complication.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 1 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. lung sounds
- B. cardiac sounds
- C. temperature
- D. blood pressure
- E. butterfly-shaped rash on face
- F. pulse oximetry
- G. pulse
Correct Answer: A,B,D,F,G
Rationale: Given the client's severe SLE exacerbation, chest pain, pallor, and diaphoresis, immediate follow-up is needed for lung sounds (A) to assess for pulmonary issues like pleural effusion, cardiac sounds (B) for pericarditis or tamponade, blood pressure (D) for hemodynamic stability, pulse oximetry (F) for oxygenation, and pulse (G) for cardiovascular status. Temperature (C) and butterfly rash (E) are less urgent in this acute context.