Correct Answer: A

Rationale: The development of autoantibodies such as antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies in systemic lupus erythematosus (SLE) is primarily attributed to a loss of self-tolerance. Self-tolerance refers to the immune system's ability to recognize and differentiate self-antigens from foreign antigens. In individuals with SLE, there is a breakdown in immune tolerance mechanisms, leading to the production of autoantibodies against self-antigens like nuclear components (e.g., DNA, RNA, histones). This loss of self-tolerance results in the immune system targeting and attacking its tissues, leading to the systemic inflammation and tissue damage characteristic of SLE. The presence of elevated levels of ANA and anti-dsDNA antibodies in this patient suggests an autoimmune response against nuclear material, further supporting the role of self-tolerance breakdown in SLE

Correct Answer: D

Rationale: Sudden chest pain, dyspnea, and tachycardia in a postpartum client can be indicative of serious conditions such as pulmonary embolism or myocardial infarction. These conditions are emergencies that require immediate medical attention. Notifying the healthcare provider immediately is the priority to ensure prompt evaluation and intervention to address the potential life-threatening situation. While other nursing interventions such as elevating the head of the bed, providing supplemental oxygen therapy, and administering analgesics may be necessary, they should be done after notifying the healthcare provider to ensure appropriate management of the underlying cause.

Correct Answer: D

Rationale: An elevation of blood pressure would warrant stoppage of pills. High blood pressure, or hypertension, in a 4-year-old child is abnormal and needs prompt medical attention. Giving pills without monitoring or stopping them if blood pressure is elevated can lead to serious health complications. It is important to address the underlying cause of high blood pressure in a child, which may require further evaluation and management by a healthcare provider.

Correct Answer: A

Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.

Correct Answer: C

Rationale: The presentation described in the question (sensation of fullness and pressure in the left ear, hearing loss, occasional tinnitus, retracted tympanic membrane with decreased mobility on pneumatic otoscopy) is suggestive of serous otitis media, also known as otitis media with effusion. Serous otitis media occurs when fluid accumulates in the middle ear without signs of infection. This buildup of fluid in the middle ear space can cause the tympanic membrane to retract and reduce its mobility on pneumatic otoscopy.