Which of the following symptoms is a classic sign of systemic lupus erythematosus (SLE)?

Correct Answer: A

Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various organs in the body. One of the classic signs of SLE is the presence of a facial rash in the shape of a butterfly over the cheeks and bridge of the nose. This rash is known as a malar rash and is often one of the first visible symptoms of the disease. Weight loss and difficulty urinating are not typical signs of SLE.

Correct Answer: A

Rationale: Encouraging a high fluid intake, typically around 3 to 4 liters daily, is an intervention that can help minimize complications related to hypercalcemia. Adequate hydration helps prevent the formation of kidney stones, a common complication of hypercalcemia. The increased fluid intake can also promote renal excretion of excess calcium, aiding in its elimination from the body. Additionally, adequate hydration supports overall kidney function and can help prevent renal damage that may result from high calcium levels.

Correct Answer: A

Rationale: The decreased white blood cell count (WBC) in the blood tests indicates a potential for infection. White blood cells are crucial for fighting off infections in the body. A decrease in WBC count can result in an impaired immune response, making the individual more susceptible to infections. Therefore, the nurse should prioritize the nursing diagnosis of "Potential for infection" to address the heightened risk of infection in the adult with anemia. It is important to monitor for signs and symptoms of infection, provide appropriate hygiene measures, and implement interventions to prevent infections in this individual.

Correct Answer: C

Rationale: Introducing variations in styles of clothing can help the client feel more comfortable and confident despite the abnormal enlargement of her arm due to lymphedema. By wearing different styles of clothing that accommodate the affected arm, the client can still express her personal style and feel good about her appearance. This approach can help improve the client's self-image and self-esteem, supporting her emotionally as she copes with the condition. Placing the arm in a sling, applying cold soaks, or tying a tight bandage are not appropriate suggestions for addressing the client's anxiety and self-image concerns in this situation.

Correct Answer: B

Rationale: Stomatitis is a common side effect of chemotherapy characterized by inflammation and irritation of the mucous membranes in the mouth. This can present as red, painful sores or ulcers on the oral mucosa. The presence of red, open sores in the mouth is indicative of stomatitis and warrants assessment and intervention to manage discomfort and prevent infection in the oral cavity. The other options are not typically associated with stomatitis in the context of chemotherapy.