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Systemic Lupus Erythematosus
The white blood cell (WBC) count of a client with systemic lupus erythematosus (SLE) shows a shift to the left. What is the highest priority nursing diagnosis for the nurse caring for this client? Impaired Skin Integrity Ineffective Individual Coping Ineffective Health Maintenance Ineffective Protection - correct answer Ineffective Protection Rationale: All of these diagnoses are appropriate for the client with SLE. However, the results of this client's WBC indicate that the client is at risk for infection due to the disease process or its treatments. Ineffective protection, then, is the highest priority of care for the nurse at this time. The nurse should instruct a client that which of the following factors might increase the risk of developing an exacerbation of systemic lupus erythematosus (SLE)? GI upset Fever Hypotension Pregnancy - correct answer Pregnancy Rationale: Pregnancy can be associated with exacerbation because of increased estrogen levels. Hypotension, fever, and GI upset do not cause exacerbation of SLE. The nurse would assess which of the following in a client who is being evaluated for systemic lupus erythematosus (SLE)? Fever
Rash on the face across the nose Elevated red blood cell count Fatigue - correct answer Rash on the face across the nose Rationale: Rash on the face across the nose is the classic sign of SLE. Fever and fatigue are symptoms that occur during exacerbations. The client with SLE is apt to be anemic. The nurse, instructing a client with systemic lupus erythematosus (SLE) about the management of fatigue during an exacerbation, would determine that learning outcomes need reinforcement if the client states a plan to: Sit when possible. Take short rest periods. Engage in low-impact exercise when not fatigued. Take a hot bath before bed. - correct answer Take a hot bath before bed. Rationale: The nurse should instruct the client to avoid hot baths to help reduce fatigue; heat can cause an exacerbation. The client should be instructed that long periods of rest can promote joint stiffness. The nurse should encourage the client to sit when possible, and to engage in low-impact exercise when not fatigued. The nurse, providing nutritional instruction for a client diagnosed with systemic lupus erythematosus (SLE), should teach the client to avoid which of the following foods? (Select all that apply.) Turkey Steak Broccoli Bacon Cantaloupe - correct answer Bacon Steak
A client with systemic lupus erythematosus (SLE) asks the nurse what medications are used to cure autoimmune diseases. The nurse should respond with which of the following? "The NSAIDS provide a cure for autoimmune diseases." "Antibiotics are used to treat autoimmune diseases." "Autoimmune diseases are not curable." "Autoimmune diseases are temporary and do not need medications." - correct answer "Autoimmune diseases are not curable." Rationale: The nurse should respond that autoimmune diseases are not curable by medications or by any other means. The client should be instructed on health promotion and management of symptoms with pharmacological and nonpharmacological methods. Antibiotics are used when the client with an autoimmune disease acquires an infection. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n) a. hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant. b. autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body. c. disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression. d. disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response. - correct answer Answer: C Rationale: SLE has an unpredictable course, even with appropriate treatment. Women are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms may worsen during pregnancy but are not confined to pregnancy or the perinatal period. All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in SLE is not caused by antibody binding to cellular estrogen receptors. A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria.
The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care? a. Institute seizure precautions. b. Reorient to time and place PRN. c. Monitor intake and output. d. Place on cardiac monitor. - correct answer Answer: C Rationale: Lupus nephritis is a common complication of SLE, and when the patient is taking corticosteroids, it is especially important to monitor renal function. There is no indication that the patient is experiencing any nervous system or cardiac problems with the SLE. A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anyplace except here to the health clinic." An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired skin integrity related to itching and skin sloughing. c. social isolation related to embarrassment about the effects of SLE. d. impaired social interaction related to lack of social skills. - correct answer Answer: C Rationale: The patient's statement about not going anyplace because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient. A patient with polyarthralgia with joint swelling and pain is being evaluated for systemic lupus erythematosus (SLE). The nurse knows that the serum test result that is the most specific for SLE is the presence of a. rheumatoid factor. b. anti-Smith antibody (Anti-Sm). c. antinuclear antibody (ANA). d. lupus erythematosus (LE) cell prep. - correct answer Answer: B Rationale: The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.
d) rash on the face across the bridge of the nose and on the cheeks - correct answer D
- Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? a) I should take hot baths because they are relaxing b) I should sit whenever possible to conserve my energy c) I should avoid long periods of rest because it causes joint stiffness d) I should do some exercises, such as walking, when I am not fatigued - correct answer A
- To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness. A 32-year-old female with systemic lupus erythematosus (SLE) complains that her hands become pale, blue, and painful when exposed to the cold. What disorder should the nurse cite as an explanation to these sign and symptoms? a) Buerger's disease occur as a result to cold exposure. b) Guillain Barre Syndrome results from very cold climate. c) Raynaud's disease results from reduced blood flow to the lower extremities when exposed to cold or stress. d) Multiple Sclerosis disease occur as a result to cold exposure. - correct answer C The nurse is assigned to care for a client with systemic lupus erythematosus. The nurse plans care, knowing that this disorder is a(n): a) local rash that occurs as a result of allergy b) disease caused by overexposure to sunlight
c) inflammatory disease of collagen contained in connective tissue d) disease caused by the continuous release of histamine in the body - correct answer C
- Systemic lupus erythematosus is an inflammatory disease of collagen in connective tissue. Options A, B, and D are not associated with this disease. The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus. The nurse reviews the physician's orders, expecting to note that which type of medication is prescribed? a) antibiotic b) antidiarrheal c) corticosteroid d) opioid analgesic - correct answer C
- Treatment of systemic lupus erythematosus is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. Options A, B, and D are not standard components of medication therapy. The nurse is teaching a client with Systemic lupus erythematosus (SLE) about self care. Which of the following teaching points is most important for the nurse to review with the client? Encourage the client to apply suntan lotion SPF 8 and higher to skin before exposure. Encourage the client to verbalize feelings of anxiety related to the diagnosis. Encourage the client to perform good hand washing after using the bathroom and before eating. Encourage the client to utilize clean technique in caring for any wound care. - correct answer Encourage the client to perform good hand washing after using the bathroom and before eating. Rationale: # 1 is incorrect because suntan lotion of an SPF 15, 30 or higher should be used since sun exposure can bring on a flare. # 2 is incorrect because psychological needs do not precede physical needs. # 3 is correct. Hand washing is the most important client needs because hand washing reduces the risk of infection
d. Difficulty urinating - correct answer A A sign of neurologic involvement in SLE is manifested by: a. CVA b. Infection c. Psychosis d. Facial tic - correct answer B A laboratory test result that supports the diagnosis of SLE is: a. Leukocytosis, elevated BUN and CREA b. Pancytopenia, elevated antinuclear antibody (ANA) titer c. Thrombocytosis, elevated ESR d. None of these - correct answer B Which of the following statements when made by the client with systemic lupus erythematosus (SLE) indicates the need for further teaching? a) I will wear long-sleeved clothings when I go walking in the morning b) I will walk in shaded areas only c) I will go sunbathing in summer d) I will wear wide-breamed hat when I go to the beach - correct answer C The client had been diagnosed to have systemic lupus erythematosus (SLE). Which of the following assessment findings should the nurse watch out for? a) pericardial friction rub b) elevated blood pressure c) tachycardia d) hemoptysis - correct answer A
the 26 year old female client is c/o low-grade fever, arthralgias, fatigue, and facial rash. which lab test should nurse expect HCP to order?
- complete metabolic panel and LFTs
- CBC and antinuclear antibody test
- cholesterol and lipid profile
- BUN and glomerular filtration test - correct answer 2. CBC and antinuclear antibody test the client diagnosed with SLE is being discharged from the medical unit. which discharge instructions are most important. select all:
- use sunscreen of SPF 30 or greater
- notify HCP of fever
- some dyspnea is expected
- the hands and feet may change color
- clt can be cured - correct answer 1-2- the nurse is developing a care plan for a client diagnosed with SLE. which goal is priority?
- maintain reproductive ability
- verbalize feelings of body image
- no deterioration of organ function
- client's skin will remain intact - correct answer 3. no deterioration of organ function
