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. restatement. Restatement involves repeating the patient’s words exactly, while here, the nurse is rephrasing the sentiment.
B. reflection. Reflection focuses on the patient’s feelings or experiences by paraphrasing their statement, helping the patient explore their feelings, which the nurse is doing here.
C. open-ended question. An open-ended question would be broad, allowing the patient to provide more information. This response is a restatement, not a question.
D. offering self. Offering self involves expressing a willingness to stay or support the patient, which is not demonstrated here.
Correct Answer is A
Explanation
A. Administering opioid and non-opioid medications together is an effective pain management strategy for severe pain. This approach can provide better pain relief by targeting different pain pathways and may reduce the total dosage of opioids needed, thus minimizing side effects.
B. Alternating IV and IM analgesic medications is not the best approach; instead, consistent pain management is necessary to keep pain levels under control.
C. Waiting until the pain score reaches 10 before administering the maximum dosage is inappropriate and could lead to inadequate pain control. Pain management should be proactive, not reactive.
D. While educating the client on narcotic dependency is important, it is not the priority intervention in this acute situation where pain control is essential. The immediate focus should be on effective pain relief.