Nokea
The nurse in the outpatient clinic is assessing a client with systemic lupus erythematosus (SLE). Which laboratory data is essential for the nurse to monitor to determine if the client is experiencing a complication?
- A. urine analysis
- B. hemoglobin A1C (HbA1C)
- C. thyroid-stimulating hormone (TSH)
- D. ammonia
Correct Answer: A
Rationale: Urine analysis is essential for monitoring complications in SLE, as it can detect proteinuria or hematuria, which are indicative of lupus nephritis, a common and serious complication. HbA1C is related to diabetes management, TSH to thyroid function, and ammonia to liver function, none of which are primary concerns for SLE complications.
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The intensive care unit (ICU) nurse is preparing to admit a client with Guillain-Barre syndrome. Which of the following items is essential for the nurse to have at the client's bedside?
- A. blood pressure cuff
- B. pulse oximeter
- C. oral intubation equipment
- D. arterial blood gas (ABG) supplies
Correct Answer: C
Rationale: Guillain-Barré syndrome can cause respiratory muscle weakness, making oral intubation equipment (C) essential for potential respiratory failure. Blood pressure cuff (A), pulse oximeter (B), and ABG supplies (D) are important but less critical than intubation readiness.
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 5 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 nurse prepares the client for an emergent pericardiocentesis and it is essential to have …………….. at the bedside. During the procedure, it is a priority for the nurse to monitor the client's ………….
- A. a bottle of sterile water
- B. a defibrillator
- C. positive pressure ventilation
- D. urinary output
- E. cardiac rhythm
- F. Gasaow coma scale
Correct Answer: B,E
Rationale: A defibrillator (B) is essential at the bedside during pericardiocentesis due to the risk of arrhythmias from needle insertion. Monitoring cardiac rhythm (E) is a priority to detect complications like ventricular arrhythmias. Sterile water (A), positive pressure ventilation (C), urinary output (D), and Glasgow Coma Scale (F) are not directly relevant.
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 6 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 nurse teaches the client self-care practices for systemic lupus erythematosus (SLE). Which two (2) client statements indicate effective understanding?
- A. I should limit my exposure to direct sunlight to 45 continuous minutes each day.
- B. I should wear long sleeves and a large-brimmed hat when outdoors.
- C. I should wash my skin with an antibacterial soap.
- D. Cosmetics must be selected carefully and should include moisturizers and sun protectors.
- E. I should refrain from receiving any vaccine.
Correct Answer: B,D
Rationale: Wearing long sleeves and a large-brimmed hat (B) and using cosmetics with moisturizers and sun protectors (D) indicate understanding of photoprotection, crucial for SLE to prevent rash exacerbation. Limiting sun exposure to 45 minutes (A) is too specific and risky, antibacterial soap (C) is unnecessary, and avoiding all vaccines (E) is incorrect as some are safe.
You are caring for a patient with Raynaud's disease who has intractable pain. The patient is scheduled to undergo surgical interruption of pain conduction pathways to improve vascular blood supply as well as eliminate vasospasm and pain. Which type of surgery is the patient most likely to undergo?
- A. Cordotomy
- B. Rhizotomy
- C. Neurectomy
- D. Sympathectomy
Correct Answer: D
Rationale: Sympathectomy (D) interrupts sympathetic nerve pathways to reduce vasospasm and improve blood flow in Raynaud's disease. Cordotomy (A) and rhizotomy (B) target pain pathways for other conditions, and neurectomy (C) involves peripheral nerve removal, less specific for Raynaud's.
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.