Systemic Lupus Erythematosus fully solved graded A+ 2023/2024

Systemic Lupus ErythematosusThe white blood cell (WBC) count of a client with systemic lupus erythematosus (SLE) shows a shift to the left. What is the highest priority nursing diagnosis for the nurse caring for this client? Impaired Skin Integrity Ineffective Individual Coping Ineffective Health Maintenance Ineffective Protection - correct answer Ineffective Protection Rationale: All of these diagnoses are appropriate for the client with SLE. However, the results of this client's WBC indicate that the client is at risk for infection due to the disease process or its treatments. Ineffective protection, then, is the highest priority of care for the nurse at this time. The nurse should instruct a client that which of the following factors might increase the risk of developing an exacerbation of systemic lupus erythematosus (SLE)? GI upset Fever Hypotension Pregnancy - correct answer Pregnancy Rationale: Pregnancy can be associated with exacerbation because of increased estrogen levels. Hypotension, fever, and GI upset do not cause exacerbation of SLE. The nurse would assess which of the following in a client who is being evaluated for systemic lupus erythematosus (SLE)? Fever Rash on the face across the nose Elevated red blood cell count Fatigue - correct answer Rash on the face across the nose Rationale: Rash on the face across the nose is the classic sign of SLE. Fever and fatigue are symptoms that occur during exacerbations. The client with SLE is apt to be anemic. The nurse, instructing a client with systemic lupus erythematosus (SLE) about the management of fatigue during an exacerbation, would determine that learning outcomes need reinforcement if the client states a plan to: Sit when possible. Take short rest periods. Engage in low-impact exercise when not fatigued. Take a hot bath before bed. - correct answer Take a hot bath before bed. Rationale: The nurse should instruct the client to avoid hot baths to help reduce fatigue; heat can cause an exacerbation. The client should be instructed that long periods of rest can promote joint stiffness. The nurse should encourage the client to sit when possible, and to engage in low-impact exercise when not fatigued. The nurse, providing nutritional instruction for a client diagnosed with systemic lupus erythematosus (SLE), should teach the client to avoid which of the following foods? (Select all that apply.) Turkey Steak Broccoli Bacon Cantaloupe - correct answer Bacon Steak Rationale: The client with SLE is at risk for cardiovascular disorders. The client should be instructed on nutritional lifestyle changes to prevent these disorders. The client should be instructed to reduce fat (steak, bacon), salt (bacon), and to quit smoking. The other food choices are part of a healthy diet. The nurse, caring for a teen diagnosed with systemic lupus erythematosus (SLE), should instruct the family about which of the following challenges? Planning meals Planning family vacations Violence from the client Adherence to treatment - correct answer Adherence to treatment Rationale: Consistent with this developmental stage, the teen client is apt to rebel more strongly and deny the disease. Adherence to a plan of treatment, medications, and the fact that this will differentiate them from the peer group can cause nonadherence. Anger at having the disease could turn to violence, but this is not typical. Planning meals and vacations should not pose problems for the family. A client with systemic lupus erythematosus (SLE) asks the nurse if getting a flu vaccine in the fall is important. The nurse responds with which of the following? "No, you could get the flu from the shot." "Yes, you should get the nasal flu vaccine." "Yes, flu vaccine is a priority every year." "No, you are not at risk for the flu." - correct answer "Yes, flu vaccine is a priority every year." Rationale: The client with SLE has a compromised immune system and should be protected from the flu with a shot every year. The flu shot is not a live virus. The nasal vaccine is a live virus and should not be used by a client with a compromised immune system. Immunization with a killed virus will not cause the disease. A client with systemic lupus erythematosus (SLE) asks the nurse what medications are used to cure autoimmune diseases. The nurse should respond with which of the following?