Nokea
The nurse suspects the client is experiencing ………………… which is classified as a(n) ……………………………
- A. rheumatoid arthritis
- B. multiple sclerosis
- C. erythematosus (SLE)
- D. anaphylaxis
- E. myasthenia gravis
- F. Hypersensitivity disorder
- G. Autoimmune disorder
Correct Answer: C,G
Rationale: The symptoms of fatigue, joint pain, facial rash worsened by sun exposure, fever, and swelling are classic for systemic lupus erythematosus (SLE) (C), an autoimmune disorder (I). Rheumatoid arthritis (A) lacks the photosensitive rash, multiple sclerosis (B) involves neurological symptoms, anaphylaxis (D) is acute, and myasthenia gravis (E) causes muscle weakness.
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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.
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.
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 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 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.