A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?
Connective tissue.
Peripheral vascular system.
Lymphatic system.
Skeletal tissue.
The Correct Answer is A
Choice A rationale
Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects connective tissue. The immune system mistakenly attacks healthy tissue, leading to inflammation and damage.
Choice B rationale
SLE does not originate in the peripheral vascular system, although it can cause complications in blood vessels.
Choice C rationale
While the lymphatic system is involved in immune responses, SLE primarily targets connective tissue.
Choice D rationale
SLE does not originate in skeletal tissue, though it can cause joint pain and arthritis.
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Correct Answer is C
Explanation
Choice A rationale
Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.
Choice B rationale
Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.
Choice C rationale
Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.
Choice D rationale
Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.
Correct Answer is A
Explanation
Choice A rationale
Administering the medications 5 minutes apart ensures that each medication has enough time to be absorbed without interference from the other. This practice helps to maximize the effectiveness of both medications and reduces the risk of adverse interactions.
Choice B rationale
Touching the tip of the dropper to the sclera of the eye can introduce contaminants and increase the risk of infection. It is important to avoid contact between the dropper and the eye to maintain sterility.
Choice C rationale
Holding pressure on the conjunctival sac for 2 minutes is not necessary for the administration of timolol and pilocarpine eye drops. This practice is more commonly recommended for other types of eye medications to increase absorption.
Choice D rationale
Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. Wearing contact lenses during administration can interfere with the effectiveness of the drops.