Correct Answer: B

Rationale: Ineffective Protection is a nursing diagnosis that involves a compromised ability to guard against health threats. Patients with systemic lupus erythematosus are prone to skin rashes, lesions, and photosensitivity due to the autoimmune nature of the disease. Providing appropriate skincare is essential in managing the skin manifestations of lupus, such as using gentle cleansers, moisturizers, and sunscreen to protect the skin from further damage. Proper skincare can help maintain skin integrity and prevent infections, which are crucial aspects of protecting patients with systemic lupus erythematosus. While monitoring laboratory findings, practicing careful hand hygiene, and administering prescribed medications are all important aspects of care for lupus patients, providing appropriate skincare directly addresses the Ineffective Protection diagnosis by focusing on protecting the patient's skin health.

Correct Answer: B

Rationale: Prinzmetal angina, also known as variant angina or vasospastic angina, is characterized by chest pain that occurs at rest, often during the night or early morning, and is unrelated to activity or emotional stress. This type of angina is caused by transient coronary artery vasospasm, which leads to a temporary reduction in blood flow to the heart. Patients with Prinzmetal angina may have normal coronary arteries or minimal atherosclerosis. It differs from stable and unstable angina, which are typically triggered by physical or emotional stress. Nonanginal pain refers to chest discomfort that is not related to cardiac causes.

Correct Answer: D

Rationale: Tobacco use is a modifiable risk factor for hypertension. Smoking cigarettes can lead to an increase in blood pressure and heart rate, as well as damage to blood vessels, which can contribute to the development of hypertension. By quitting smoking or avoiding tobacco use, individuals can reduce their risk of developing hypertension and improve their overall cardiovascular health. On the other hand, factors such as age, ethnicity, and family history are non-modifiable risk factors for hypertension, meaning individuals cannot change them through lifestyle modifications.

Correct Answer: D

Rationale: Asking the client about their preferred learning strategies is the appropriate action at this time. Everyone learns in different ways, and by identifying the client's preferred learning style, the nurse can tailor the teaching session to be more effective and memorable for the client. Understanding how the client learns best can help in providing information in a way that is easier for them to retain and recall later. It also demonstrates a client-centered approach to teaching, which can improve communication and understanding between the client and the healthcare provider.

Correct Answer: B

Rationale: The nursing diagnosis of Activity Intolerance is the most appropriate for a client with a cardiac dysrhythmia who reports being easily fatigued and having difficulty performing normal daily activities. Cardiac dysrhythmias can lead to decreased cardiac output, which can result in reduced oxygen delivery to the body's tissues, contributing to fatigue and weakness. Activity Intolerance is defined as the state in which an individual experiences or is at risk of experiencing insufficient physiological or psychological energy to endure or complete daily activities. This diagnosis is fitting for the client's inability to perform normal daily activities due to the cardiac dysrhythmia-induced fatigue and weakness. Addressing Activity Intolerance will involve collaborating with the client to set achievable activity goals and incorporating periods of rest to enhance tolerance to physical activity and improve overall function.