NUR200 - M2 - Lupus - NCLEX and ATI

1. A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply.) A. Positive ANA titer B. Increased hemoglobin C. 2+ urine protein D. Increased serum C3 and C4 E. Elevated BUN

1. A. CORRECT: A positive antinuclear antibody (ANA) titer is an expected finding in a client who has SLE. The ANA test identifies the presence of antibodies produced against the client's own DNA. B. Pancytopenia, rather than an elevated hemoglobin, is an expected finding in a client who has SLE. C. CORRECT: Increased urine protein is an expected finding due to kidney injury as a result of SLE. D. The client who has SLE is expected to have a decreased level of serum C3 and C4. E. CORRECT: Elevated BUN is an expected finding due to kidney injury in a client who has SLE. NCLEX® Connection: Reduction of Risk Potential, Laboratory Values

3. A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply.) A. Diuretic use B. Obesity C. Deep sleep deprivation D. Depression E. Cardiovascular disease

3. A. CORRECT: The use of diuretics is a risk factor for gout. B. CORRECT: Obesity is a risk factor for gout. C. Deep sleep deprivation is a manifestation of fibromyalgia and is not a risk factor for gout. D. Depression is a manifestation of SLE and is not a risk factor for gout. E. CORRECT: Cardiovascular disease is a risk factor for gout. NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my time to 10 minutes in the tanning bed." B. "I will apply powder to any skin rash." C."I should use a mild hair shampoo." D."I will inspect my skin once a month for rashes."

2. A. A client who has SLE should avoid the use of tanning beds, as well as prolonged sun exposure. B. A client who has SLE should apply steroid-based creams to skin rashes, not a powder. C. CORRECT: A client who has SLE should use a mild hair shampoo that does not irritate the scalp. D. A client who has SLE should inspect her skin daily for any open areas or rashes. NCLEX® Connection: Physiological Adaptation, Illness Management

4. A nurse is assessing a client who has SLE. Which of the following findings should the nurse expect? A. Weight loss B. Petechiae on thighs C. Systolic murmur D. Alopecia

4. A. Weight gain can occur in a client who has SLE due to being treated with corticosteroids. This is an adverse effect of this medication. B. A butterfly rash on the face is a finding in a client who has lupus. C. A cardiac friction rub is an expected finding of SLE. D. CORRECT: Alopecia (hair loss) is an expected finding in a client who has SLE. NCLEX® Connection: Physiological Adaptation, Pathophysiology

5. A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? A. Swelling of joints of the fingers B. Pallor of toes with cold exposure C. Feet that become reddened with ambulation D. Client report of intense feeling of heat in the fingers

5. A. Swelling, pain, and joint tenderness are findings in a client who has SLE and is not specific to an episode of Raynaud's phenomenon. B. CORRECT: Pallor of the extremities occurs in Raynaud's phenomenon in a client who has SLE and has been exposed to cold or stress. C. The extremities becoming red, white, and blue when exposed to cold or stress is characteristic of an episode of Raynaud's phenomenon in a client who has SLE. D. A client report of intense pain in the hands and feet is characteristic of an episode of Raynaud's phenomenon in a client who has SLE. NCLEX® Connection: Physiological Adaptation, Pathophysiology

4) The nurse is caring for a client who is hospitalized due to an exacerbation of systemic lupus erythematosus (SLE). The nurse is reviewing the client's lab work and finds the white blood cell count (WBC) is shifted to the left. Based on this information, which is a priority nursing diagnosis for this client? A) Ineffective Protection B) Ineffective Health Maintenance C) Ineffective Individual Coping D) Risk for Impaired Skin Integrity

Answer: A Explanation: A) All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential is indicative of a large number of immature cells, suggesting infection, and is therefore the priority for the client with the diagnosis Ineffective Protection. Page Ref: 516 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with systemic lupus erythematosus.

1) The client enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks. Which diagnosis does the nurse expect? A) Systemic lupus erythematosus B) Fibromyalgia C) Lyme disease D) Gout

Answer: A Explanation: A) The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder will have this rash. While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do not cause a rash over the nose and cheeks. Page Ref: 510 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of systemic lupus erythematosus.

9) The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which client statement indicates plan of care understanding? A) "I will take birth control pills while I am taking cytotoxic medications." B) "I do not need to contact the doctor if I develop a fever or rash." C) "I plan to go to the movies this weekend so that I get out of the house." D) "I can take ibuprofen as indicated for pain."

Answer: A Explanation: A) Treatment for SLE can include cytotoxic drugs. The client is taught to avoid pregnancy by using contraceptives, as these drugs can cause birth defects. The client is taught to avoid crowds, as they are potential sources of infection. Client with SLE should contact their primary care providers should signs of infection occur, as the immune system is compromised. Aspirin and ibuprofen can cause bleeding and should be taken with extreme care. Page Ref: 514 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.

11) A nurse caring for a client with SLE on immunosuppressive therapy understands that careful teaching is required to make sure both clients and family members understand appropriate precautions against the threat of infection. Teaching points should include: Select all that apply. A) Avoid large crowds and situations that increase exposure to infection. B) Report difficulty breathing or cough to the physician if taking cyclophosphamide. C) Use ibuprofen instead of acetaminophen if fever develops. D) Women may develop heavy menstrual bleeding during therapy.

Answer: A, B Explanation: A) The nurse should teach the client and family regarding avoiding large crowds and situations that increase exposure to infection and to report difficulty breathing or cough. The client should report a fever if it develops, and ibuprofen should not be used, as this may increase the risk for bleeding. Women may have an absence of menstruation, not heavy bleeding, during therapy. Page Ref: 514 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

5) A client with SLE is being treated with immunosuppressant drugs and corticosteroids. Which precautions should the nurse provide this client? Select all that apply. A) Avoid large crowds. B) Don't get a flu shot. C) Use contraception to prevent pregnancy D) Refrain from taking aspirin or ibuprofen. E) Report signs of infection to the physician.

Answer: A, C, D, E Explanation: A) Crowds may increase exposure to infection. Annual influenza vaccination is recommended but clients with significant immunosuppression should not receive live vaccines. Immunosuppressive drugs may increase the risk of birth defects. Aspirin or ibuprofen may increase the risk of bleeding. Chills, fever, sore throat, fatigue, or malaise should be reported. Page Ref: 516 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with systemic lupus erythematosus.

6) A nurse is caring for a client with systemic lupus erythematosus (SLE). The client begins to cry and tells the nurse that she is afraid that her skin will be disfigured with lesions. Which intervention does the nurse plan to teach this client to minimize skin infections associated with SLE? Select all that apply. A) Use sunscreen with an SPF of 15 or greater. B) Remain indoors on sunny days. C) Avoid swimming in a pool or the ocean. D) Avoid sun exposure between 10:00 a.m. and 3:00 p.m. E) Decrease sun exposure between 3:00 p.m. and 5:00 p.m.

Answer: A, D Explanation: A) The nurse teaches the client to live a normal life with a few extra precautions. There is a relationship between sun exposure and infection, so the client is taught to use sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m. Page Ref: 513 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 6. Plan evidence-based care for an individual with systemic lupus erythematosus and his or her family in collaboration with other members of the healthcare team.

7) The nurse is caring for a client who has been diagnosed with discoid lupus erythematosus. The nurse is collaborating with the client to set goals for the nursing plan of care. What is an appropriate goal for this client? A) Work through the stages of death and dying. B) Comply 100% of the time with a sun protection plan. C) Gain weight to within 10 pounds of normal for height. D) Report pain no higher than four on a scale of 1-10.

Answer: B Explanation: A) Discoid lupus erythematosus is an autoimmune disorder of the skin, so the client must protect against the sun to avoid skin cancers and other complications. It is not fatal, is not related to weight, and is rarely painful unless complications arise. Page Ref: 515 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation Learning Outcome: 7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.

10) A nurse is caring for a client with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). The nurse understands that the primary concern with this drug is: A) Pulmonary fibrosis. B) Cushingoid effects. C) Retinal toxicity. D) Renal toxicity.

Answer: C Explanation: A) Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal toxicity and possible irreversible blindness. Cushingoid effects are a concern with corticosteroid therapy. Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil. Renal toxicity is not the primary concern with Plaquenil. Page Ref: 514 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

2) A female client asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE). Which is the best nurse response? A) "Conditions that cause hypotension can often exacerbate SLE." B) "GI upset is often associated with SLE exacerbation." C) "Pregnancy is often associated with an SLE exacerbation." D) "Fever is a known trigger for an SLE exacerbation."

Answer: C Explanation: A) Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels. Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE. Page Ref: 510 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 2. Identify risk factors and prevention methods associated with systemic lupus erythematosus.

3) The nurse is providing health education to a diverse group at a neighborhood community center. Why does the nurse plan to include signs and symptoms of systemic lupus erythematosus (SLE)? A) The neighborhood is composed of many young female children. B) The audience has asked the nurse to include the information. C) The audience is mainly composed of Caucasian women. D) The audience is mainly females of Asian-American descent.

Answer: D Explanation: A) Among women who are of child-bearing age, SLE is seen in more African-Americans, Hispanics, and Asian-Americans than Caucasians. There is no evidence that the audience asked for the information. Page Ref: 510 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with systemic lupus erythematosus.

8) The nurse is planning care for an adolescent client who has systemic lupus erythematosus (SLE). The nurse knows that the treatment plan implemented by the healthcare team is appropriate for the situation when the client: A) Refuses to attend school. B) Does not want to attend any social functions. C) Discusses skin changes with the healthcare personnel. D) Discusses skin changes with a good friend.

Answer: D Explanation: A) Peer interaction is important to teens. Being able to discuss the physical changes related to SLE with a friend indicates acceptance of the change in body image. Refusing to go to school or attend social functions indicates nonacceptance of the changes to body image. Discussing changes only with healthcare personnel does not indicate the teen has adjusted to the body image changes. Page Ref: 515 Cognitive Level: Analyzing Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 7. Evaluate expected outcomes for an individual with systemic lupus erythematosus.