The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

Correct Answer: D

Rationale: In a client with systemic lupus erythematosus (SLE), a urine output of 20 mL/hour is the most concerning finding. This is indicative of potential renal complications, such as lupus nephritis, which is a common and serious manifestation of SLE that can lead to kidney damage and failure if not promptly addressed. Monitoring urine output is crucial in assessing renal function in SLE patients. The other options are less concerning in the context of SLE. Chronic fatigue (Option A) is a common symptom in SLE due to the chronic inflammatory nature of the disease. A butterfly rash (Option B) is a classic dermatological manifestation of SLE but does not pose an immediate threat to the client's health. A blood pressure of 126/85 mm Hg (Option C) falls within the normal range and is not specifically alarming in a client with SLE unless there are other symptoms of hypertension present. Educationally, understanding the significance of monitoring urine output in SLE patients is vital for nurses caring for these individuals. Renal involvement is a serious complication of SLE that requires early detection and management to prevent further damage. This question reinforces the importance of recognizing and prioritizing critical findings in SLE patients to provide timely and appropriate care.

Correct Answer: A

Rationale: In the context of skin integrity, regular exercise positively affects skin health in multiple ways. Exercise improves blood circulation, which helps deliver essential nutrients and oxygen to the skin cells, promoting cell regeneration and repair. It also helps in reducing stress, which can have a positive impact on skin conditions like acne and eczema. Moreover, exercise promotes better sleep, which is crucial for skin rejuvenation and repair. On the other hand, options B, C, and D have negative impacts on skin integrity. Tattoos involve puncturing the skin, which can lead to infections and scarring if not done properly. Smoking restricts blood flow to the skin, depriving it of essential nutrients and oxygen, leading to premature aging and skin damage. Tanning, whether from the sun or tanning beds, exposes the skin to harmful UV rays, increasing the risk of skin cancer and accelerating skin aging. From an educational perspective, understanding the effects of lifestyle habits on skin integrity is crucial for healthcare professionals to educate patients on maintaining healthy skin. By highlighting the benefits of regular exercise and the detrimental effects of tattoos, smoking, and tanning, healthcare providers can empower individuals to make informed choices to promote skin health and overall well-being.

Correct Answer: B

Rationale: In the context of caring for a client with osteoarthritis, the goal of medication therapy is to reduce pain and inflammation (Option B). Osteoarthritis is a chronic condition characterized by joint pain and inflammation, and medications are used to help manage these symptoms to improve the individual's quality of life. Option A, eradicating the disease, is not possible as osteoarthritis is a degenerative condition that cannot be cured completely with current medical treatments. Option C, turning on the immune system, is incorrect because osteoarthritis is not an autoimmune condition where immune system activation would be beneficial. Option D, managing weight loss, while important for overall health and can help reduce strain on joints, is not the primary goal of medication therapy for osteoarthritis. Educationally, understanding the goals of medication therapy in osteoarthritis helps nurses provide effective care to clients with this condition. By addressing pain and inflammation, medications can help improve mobility, decrease disability, and enhance the client's ability to engage in daily activities. This knowledge is essential for providing holistic care and promoting the well-being of individuals with osteoarthritis.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D, the older adult with a hip fracture who is immobile, as they are at the highest risk for skin breakdown. The rationale behind this is that immobility can lead to prolonged pressure on certain areas of the body, increasing the likelihood of developing pressure ulcers. Older adults have thinner, more fragile skin and decreased blood flow, further predisposing them to skin breakdown. Option A, the adolescent with a patella fracture in an immobilizer, is at risk but typically has better skin integrity due to younger age and more robust circulation. Option B, the young adult with a femur fracture going to surgery soon, is not immobile for an extended period, reducing the risk of skin breakdown. Option C, the middle-aged adult with a fractured radius and a cast, is also at risk but less so than the immobile older adult. Educationally, this question highlights the importance of recognizing risk factors for skin breakdown, especially in immobile patients. Nurses must prioritize preventative measures such as regular repositioning, skin assessments, and moisture management to mitigate the risk of pressure ulcers in such high-risk individuals.

Correct Answer: A

Rationale: In this scenario, the nurse's priority action for a client with compromised immunity is option A) Wash hands before entering the client's room. This is the correct answer because proper hand hygiene is crucial in preventing the transmission of infections, especially to individuals with compromised immunity who are more susceptible to infections. By washing hands before entering the client's room, the nurse reduces the risk of introducing harmful pathogens to the client, thus promoting their safety and well-being. Option B) Take the client's vital signs every 4 hours is not the priority action in this case. While monitoring vital signs is essential in patient care, ensuring proper hand hygiene to prevent infections takes precedence, particularly for a client with compromised immunity. Option C) Determine whether it is temporary or permanent is not the priority action as well. While understanding the nature of the client's compromised immunity is important for long-term care planning, immediate infection prevention through hand hygiene is more critical in ensuring the client's safety. Option D) Teach the family members to receive the flu shot annually is not the priority action either. While educating family members about preventive measures is beneficial for the client's overall health, the immediate need to prevent infections through hand hygiene is more pressing in this case. In an educational context, understanding the rationale behind the priority actions in caring for clients with compromised immunity is vital for nursing practice. Emphasizing the significance of infection control measures, such as hand hygiene, not only protects the clients but also helps instill a culture of patient safety among healthcare providers. By prioritizing actions that directly address the immediate risk to the client's health, nurses can effectively promote positive outcomes and quality care delivery.