A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?
Joint pain.
Low grade fever.
Muscle atrophy.
Hematuria.
The Correct Answer is D
A. Joint pain is a common symptom of systemic lupus erythematosus (SLE) and, while it may indicate an exacerbation of the disease, it is not the most critical finding to report.
B. A low-grade fever can signify an infection or increased disease activity but is generally not as urgent as changes in renal function or systemic involvement.
C. Muscle atrophy is a concern over time but does not pose an immediate threat to the client’s health compared to acute changes in kidney function.
D. Hematuria is significant in SLE as it can indicate renal involvement, such as lupus nephritis, which can lead to severe complications. This finding requires prompt reporting and assessment to prevent further renal damage and manage potential complications effectively.
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Correct Answer is B
Explanation
A. While having the client sign permits is important, it is not the priority action in this situation.
B. Notifying the healthcare provider about the client's current heparin therapy is critical, as it may influence the timing of surgery and the risk of excessive bleeding during and after the procedure.
C. While explaining the potential for bleeding is important, it should occur after ensuring the surgical team is aware of the heparin use.
D. Observing injection sites for bruising is relevant but does not address the immediate concern regarding heparin use and potential bleeding during surgery.
Correct Answer is C
Explanation
A. Immediately after the patient has been medicated for pain.
While pain relief may help, education should be conducted when the patient is alert and comfortable, not immediately after pain medication when they may be drowsy.
B. The last thing in the evening, after visitors have left, before bedtime. Education right before bedtime may not be effective if the patient is tired, as retention and attention may be reduced.
C. When the patient is comfortable and receptive to the patient education.
Teaching should occur when the patient is comfortable, alert, and receptive to ensure they can retain and understand the information.
D. Just before the patient is discharged, so the information is current.
Waiting until discharge could overwhelm the patient, and they may not have time to ask questions or clarify information.