NUR 211 Test 7
1. A Nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the
following findings should the nurse expect?
Facial rash
Thickened skin
Chronic back pain
Iritis
Answer
Facial rash
Rationale
SLE causes a characteristic facial "butterfly" rash that is dry, scaly, red, and raised
2. A nurse is providing discharge teaching to a client who has systemic lupus erythematosus
(SLE). Which of the following instructions should the nurse include?
Avoid using moisturizing lotions on the skin
Wash the hair with a mild protein shampoo.
Applypowder liberally to sensitive skin areas.
Use a sun-blocking agent with a sun protection of at least 15.
Answer
Use a sun-blocking agent with a sun protection of at least 15.
Rationale
Clients who have SLE are prone to hair loss. They should use a mild protein shampooand ... avoid
treatments that can damage the hair and scalp, such as dyes and permanents.
Clients who have SLE should not use powder or other drying skin products on their skin. Clients
who have SLE should apply non-perfumed moisturizing lotions liberally to the skin
3. A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus
(SLE) and asks where this disease originates within the body. The nurse should tell the client
that SLE originates in which of the following locations in the body?
Connective tissue
Muscle tissue
,Peripheral vascular system
Answer
Connective tissue
Rationale
SLE originates in the connective tissues of the body and affects all organ systems.
4. A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the
following findings is the highest priority for the nurse to report to the provider?
Client reports mild feelings of depression
Dry, raised rash on the face.
Presence of sudden peripheral edema.
Joint pain in hands and knees.
Answer
Presence of sudden peripheral edema.
Rationale
The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to
the safety and risk reduction priority setting framework, findings that indicate animpairment of
renal function are the highest priority to report.
Rationale
The client who has SLE commonly reports joint pain and rash. However, according toRationale
The client who has SLE commonly reports feelings of depression. However, according to the
safety and risk reduction priority setting framework, these other findings are not the highest
priority.
5. A nurse is assessing a client who is taking hydroxychloroquine. The nurse should report
which of the following adverse effects to the provider immediately?
Blurry vision
Diarrhea
Fatigue
Pruritus
Answer
Blurry Vision
, Rationale
When using the urgent vs non-urgent approach to client care, the nurse should
determine that the priority finding to report to the provider is blurred vision, as this is a
manifestation of hydroxychloroquine toxicity and can be an indication of retinal
damage.
6. A nurse is teaching a female client who has a new diagnosis of systemic lupus
erythematosus (SLE). The nurse should recognize the need for further teaching when the client
identifies which of the following as a factor that can exacerbate SLE?
Exercise
Infection
Pregnancy
Sunlight
Answer
Exercise
Rationale
Deconditioning and muscle atrophy occurs as a result of lack of mobility. The nurseshould
encourage client to engage in conditioning exercises alternated with periods of rest.
Rationale
Exposure to sunlight and artificial ultraviolet light can cause for an exacerbation of SLE
manifestations, especially the characteristic skin manifestations of lesions and butterfly rash.
Rationale
Pregnancy can cause an exacerbation of SLE, probably due to hormonal changes. The client
should be advised of the risks and must be monitored closely for effects on the renal and
cardiovascular systems if she decides to get pregnant.
Rationale
Infection is a major stressor on the body and can trigger an exacerbation of the SLE disease
process. In addition, many clients who have SLE take steroid medications that place them at
higher risk for infection.
7. A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus
(SLE). Which of the following values should give the nurse the best indication of the client's
renal function?
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