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 D
Explanation
Choice A rationale
Speaking loudly and into the client’s good ear is not recommended. Loud speech can be distorted and uncomfortable for individuals with presbycusis.
Choice B rationale
Using sign language is not necessary unless the client is proficient in it. Most clients with presbycusis benefit more from clear verbal communication.
Choice C rationale
Sitting by the client’s side and speaking very slowly is not as effective as speaking directly to the client in a normal, clear voice.
Choice D rationale
Speaking directly to the client in a normal, clear voice is recommended. This ensures that the client can read lips and understand the conversation better.
Correct Answer is D
Explanation
Choice A rationale
Allowing the client to ambulate one day after a detached retinal repair is not recommended. Ambulation can increase intraocular pressure and disrupt the healing process of the retina. The client should be advised to limit physical activity to prevent any strain on the eye.
Choice B rationale
Removing the eye patch during the day is not advisable as it can expose the eye to potential injury or infection. The eye patch helps protect the eye and maintain the correct position for healing. It should be worn as directed by the healthcare provider.
Choice C rationale
Encouraging coughing and deep-breathing exercises is not appropriate for a client who has undergone retinal repair. These activities can increase intraocular pressure and risk detachment of the retina. The client should avoid activities that cause strain or pressure on the eyes.
Choice D rationale
Avoiding reading and writing is crucial for a client one day postoperative following a detached retinal repair. These activities can cause rapid eye movements and strain, which can interfere with the healing process and reattachment of the retina. The client should be advised to rest their eyes and avoid any activities that require intense focus or eye movement.