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Systemic lupus Erythematosus HESI Case Study

Terms in this set (25)

Which pathophysiological process promotes systemic lupus erythematosus (SLE)?
Production of autoantibodies against nucleic acids and other self-components.
The initial anticipated nursing intervention is to accurately record the severity of systemic lupus erythematosus (SLE) symptoms. For which acute conditions should the nurse assess Ms. Santos? (Select all that apply.)
-joint inflammation
-fatigue level
-fever pattern
Which assessment finding should alert the nurse that teaching is needed to prevent skin breakdown?
Prominent tan lines on the back.
About which potential complication of systemic lupus erythematosus (SLE) should the nurse warn the client?
Increased risk for bleeding or blood clotting.
The healthcare provider has written several admission prescriptions for Ms. Santos. Which prescription should the nurse ask the healthcare provider to clarify?
Prednisone PO daily.
The healthcare provider clarifies the prescription as Prednisone 30 mg PO daily. The nurse prepares to give the first dose of prednisone. Which client education elements should the nurse highlight with Ms. Santos? (Select all that apply.)
-Do not suddenly stop taking this medication; it should be tapered.
-Take this medication in the morning with food to avoid GI disturbance.
-Do not have any live virus vaccinations while taking this medication.
After giving the prednisone as prescribed, what should the nurse do first?
Sign the drug off in the electronic health record.
The nurse returns to Ms. Santos's room to assess her physical response to the medication she took an hour ago. Ms. Santos is very quiet. The nurse asks Ms. Santos if she is feeling alright after taking the prednisone, and she hesitates for a moment and then says, "yes." Which action is the best response by the nurse?
Ask the client about how she is feeling in general right now.
The nurse is concerned that Ms. Santos is not coping very well with her chronic illness and that she is very quiet. Which responses are helpful for the nurse give to this client? (Select all that apply.)
-What you are experiencing is very hard.
-How are you doing this afternoon, Ms. Santos?
The nurse is preparing to develop a personalized care plan for Ms. Santos. Which approach to initiating this process would be most effective?
Ask the client about what her daily life and what health means to her.
The nurse is assessing the importance of client culture and ethnicity while planning care with Ms. Santos. Which questions would be helpful for gathering this information? (Select all that apply.)
-How are medical decisions made in your family?
-What are some activities that you enjoy doing?
-Are there any special foods that you like to eat?
-Do you believe in and worship a supreme being?
-What languages are typically spoken in your home?
The nurse comes to Ms. Santos's room, which is crowded with people. Several conversations are going simultaneously. Two school aged children are quietly sitting on the floor playing a game called Pitik-Bulog. Which action should the nurse perform next?
Establish a family information and decision-making protocol.
A few hours later, the unlicensed assistive personnel (UAP) informs the nurse that Ms. Santos has refused her dinner tray. As the nurse comes to Ms. Santos's room, her mother opens a sealed plastic bowl full of rice soup and gives her a spoon. Which intervention is the most important for the nurse to perform?
Note and document the approximate volume of soup.
The nurse assesses Ms. Santos's lifestyle choices to explore what resources she has for health promotion. Which lifestyle choice may concern the nurse about a client with systemic lupus erythematosus (SLE)? (Select all that apply.)
-She enjoys sun bathing beside the pool at her house.
-She wants to become pregnant in the next year or two.
-She says that "this disease process is all in the hands of God."
-She is a devout Catholic who does not use contraception.
The nurse teaches Ms. Santos how to manage her systemic lupus erythematosus (SLE) when she experiences a flare. Which element of self-care will be most important to her condition?
Pacing daily activities to conserve energy.
The nurse is providing Ms. Santos with evidence-based approaches for reducing the incidence of systemic lupus erythematosus (SLE) flares. Which elements of self-care are relevant to her condition? (Select all that apply.)
-Adhering to the medication regimen.
-Getting plenty of rest and relaxation.
-Reducing the stress in her daily life.
The nurse is evaluating the effectiveness of teaching Ms. Santos about her daily dietary intake. Which response would demonstrate that diet teaching has been effective?
Eat foods high in calcium and vitamin D, such as milk.
While preparing to leave the room and see the next client, the healthcare provider advises Ms. Santos that she should avoid pregnancy for the rest of her life due to the many serious complications that can arise with systemic lupus erythematosus (SLE).
Ms. Santos is devastated by this advice and the nurse supports her with therapeutic presence and information. About which common complications in pregnant women with SLE should the nurse inform her? (Select all that apply.)
-Severe postpartum exacerbation.
-Stillbirth and neonatal death.
-Spontaneous abortion.
-Intrauterine growth defects.
Ms. Santos has informed the nurse and healthcare team that she does not wish to have birth control and that everything is in God's hands now. If she becomes a mother someday, it will be God's will for her. The healthcare provider takes the nurse aside and asks that more time be spent convincing her that contraception should be instituted as soon as possible. Which response is the best reply from the nurse?
Her right to refuse contraception should be respected.
The nurse anticipates that Ms. Santos will have some difficulty with changes in her body image due to the illness and the advice that she should not become pregnant. Which method is best for evaluating the impact of body image changes on the client?
Listen closely to how the client describes her self-care routine.
How should the nurse assess the stressors that are affecting Ms. Santos's nursing care?
-Explore with the client which stressors are confronting her now.
-Note the strategies she has used previously to cope with stress.
-Document any major losses experienced within the previous year.
The nurse plans to implement a measure to reduce environmental stress for Ms. Santos. Which action is most likely to be effective?
Teaching her how to use relaxation breathing techniques.
Ms. Santos is discussing her sleep rest patterns with the nurse. She agrees with the nurse that she should improve her ability to get adequate rest and sleep each night to reduce stress and the chances of new flares developing. Which intervention would be helpful for improving sleep quality for a client with SLE who suffers from fatigue?
Establishing a regular daily sleep-wake routine.
The nurse evaluates Ms. Santos's understanding of the health promotion activities they have discussed in previous conversations in preparation for discharge to home. Which health promotion activities mentioned by the client assure the nurse that learning has been effective? (Select all that apply.)
-Take prednisone by mouth as prescribed.
-Eat foods high in calcium and vitamin D.
-Reduce environmental and emotional stress.
-Establish an effective sleep-wake routine.
Which client teaching point is the most important thing for the nurse to emphasize when giving Ms. Santos her discharge information?
Do not suddenly stop taking the prednisone medication.
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