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 A
Explanation
Choice A rationale
A CD4-T-cell count of 180 cells/mm³ indicates severe immunosuppression in a client with HIV, making them highly susceptible to opportunistic infections. This is a critical value that requires immediate attention to prevent life-threatening complications.
Choice B rationale
A positive Western blot test confirms the presence of HIV antibodies but does not indicate the current immune status or the urgency of the client’s condition.
Choice C rationale
Platelets at 150,000/mm³ are within the normal range and do not indicate an immediate threat to the client’s health.
Choice D rationale
A WBC count of 5,000/mm³ is within the normal range and does not indicate an immediate threat to the client’s health.
Correct Answer is C
Explanation
Choice A rationale
Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.
Choice B rationale
Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.
Choice C rationale
Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.
Choice D rationale
Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.