Question

A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

Answer 1

Correct Answers:

Pallor of the toes with cold exposure

Rationale :

🔹 Raynaud’s phenomenon is triggered by cold or stress, causing vasospasm in the digits.

🔹 Pallor is the first color change due to lack of blood flow during vasoconstriction.

🔹 The episode typically progresses from pallor → cyanosis → redness once circulation returns.

🔹 Fingers or toes become cold and numb as perfusion decreases.

🔹 It is commonly associated with autoimmune diseases like SLE.

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Answer 2

Correct Answers:

"I should use a mild hair shampoo"

Rationale :

🔸 Patients with SLE are prone to alopecia and sensitive skin due to inflammation and photosensitivity.

🔸 Use of gentle, mild shampoos minimizes irritation to the scalp.

🔸 Strong chemicals or harsh products can exacerbate skin rashes or hair loss.

🔸 Avoiding tanning beds and sun exposure is critical in lupus self-care.

🔸 Monitoring for skin rashes should be done daily, not monthly.

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Answer 3

Correct Answers:

"You can experience morning stiffness when you get out of bed"

Rationale :

✳️ Morning stiffness lasting more than 30 minutes is a hallmark of rheumatoid arthritis.

✳️ It results from joint inflammation and synovial thickening.

✳️ Patients often report difficulty starting movements, improving with activity.

✳️ The stiffness is bilateral and commonly affects hands and fingers.

✳️ This symptom helps differentiate it from osteoarthritis, which worsens with use.

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Answer 4

Correct Answers:

Positive ANA titer
2+ urine protein
Elevated BUN

Rationale :

💎 Positive ANA titer ANA is a key marker for autoimmune conditions like SLE.

B. 2+ urine protein

💎 Indicates kidney involvement, commonly lupus nephritis.

💎 Elevated BUN Reflects renal impairment, common in advanced SLE flares.

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Answer 5

Correct Answers:

"I will add high-protein foods or finger foods to my diet"

Rationale :

💠 HIV Stage 2 may involve unintentional weight loss, so nutritional support is vital.

💠 High-protein foods support tissue repair and immune strength.

💠 Finger foods are often better tolerated and more appealing during anorexia or fatigue.

💠 Frequent small meals help maintain caloric intake.

💠 Adequate hydration is needed, but not limited to 1 liter daily.

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Answer 6

Correct Answers:

Alopecia

Rationale :

♦ Hair loss is a common manifestation of SLE, due to autoimmune skin involvement.

♦ It may be diffuse or patchy and is often exacerbated by UV exposure.

♦ Petechiae would suggest thrombocytopenia, not specific to SLE at diagnosis.

♦ Weight loss, not gain, is more typical in active autoimmune disease.

♦ Systolic murmurs are not a common primary SLE sign.

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Answer 7

Correct Answers:

“I will wear gloves while changing the kitty litter box"

Rationale :

🟣 HIV Stage 3 (AIDS) patients are highly immunocompromised and at risk for toxoplasmosis, found in cat feces.

🟣 Wearing gloves reduces exposure to opportunistic pathogens.

🟣 Raw fruits and vegetables should be washed thoroughly or cooked.

🟣 No need for N95 masks unless in high-risk settings; surgical masks suffice.

🟣 Cooking vegetables ensures removal of potential parasites and bacteria.

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Answer 8

Correct Answers:

Hematochezia
Tarry stool
Coffee-ground emesis
Hematemesis

Rationale :

⬖ Hematochezia – Indicates lower GI bleeding, such as from hemorrhoids or diverticulosis.

⬖ Tarry stool – Melena from upper GI bleeding, such as ulcers.

⬖ Coffee-ground emesis – Indicates partially digested blood from upper GI.

⬖ Hematemesis – Vomiting fresh blood from esophageal or gastric bleeding.

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Answer 9

Correct Answers:

Hypovolemic

Rationale :

🔷 Post-surgical infection and fluid loss from purulent drainage and systemic vasodilation can lead to fluid volume depletion.

🔷 Blood pressure drop is a classic sign of hypovolemia.

🔷 This condition occurs when there’s a significant loss of blood or fluids, compromising perfusion.

🔷 Hypovolemic shock is marked by hypotension, tachycardia, pallor, and weak pulses.

🔷 Requires rapid IV fluid resuscitation.

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Answer 10

Correct Answers:

TPN should flow through a filtered IV line
No other drugs should be infused through the TPN line
If TPN gets stopped or runs out, hang a bag of D10% W
TPN IV tubing and bag should be changed every 24 hrs
TPN should be administered through a central line

Rationale :

◈ Filtered IV line – Removes particulates or contaminants from the high-glucose solution.

◈ No other drugs in line – Prevents precipitation or incompatibility reactions.

◈ Hang D10%W if TPN stops – Prevents rebound hypoglycemia.

◈ Change tubing/bag every 24 hrs – Reduces infection risk.

◈ Administer via central line – High osmolality of TPN can damage peripheral veins.

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Med surg exam CNI College00

No.

1 :
A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

2 :
A nurse is teaching a client who has SLE (Lupus) about self-care. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching?

4 :
A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply)

5 :
A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

6 :
A nurse is assessing a client who has a new diagnosis of SLE (Lupus). Which of the following findings should the nurse expect?

7 :
A nurse is providing teaching for a client who has stage 3 HIV disease (AIDS). Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

8 :
Which of the following are common signs or symptoms of GI bleeding? (Select all that apply)

9 :
Your patient had an open colon resection a week ago and developed a subsequent infection of their surgical incision. Now the patient's blood pressure has been dropping for the past 2 hours and is currently 89/65. What type of shock is the patient experiencing?

10 :
Which of the following is are appropriate nursing interventions to ensure the safety of a patient who is receiving Total Parenteral Nutrition (TPN)? (Select all that apply)

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Med surg exam CNI College00

No.

1 : A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

2 : A nurse is teaching a client who has SLE (Lupus) about self-care. Which of the following statements by the client indicates an understanding of the teaching?

3 : A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching?

4 : A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply)

5 : A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

6 : A nurse is assessing a client who has a new diagnosis of SLE (Lupus). Which of the following findings should the nurse expect?

7 : A nurse is providing teaching for a client who has stage 3 HIV disease (AIDS). Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

8 : Which of the following are common signs or symptoms of GI bleeding? (Select all that apply)

9 : Your patient had an open colon resection a week ago and developed a subsequent infection of their surgical incision. Now the patient's blood pressure has been dropping for the past 2 hours and is currently 89/65. What type of shock is the patient experiencing?

10 : Which of the following is are appropriate nursing interventions to ensure the safety of a patient who is receiving Total Parenteral Nutrition (TPN)? (Select all that apply)

1 :
A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

2 :
A nurse is teaching a client who has SLE (Lupus) about self-care. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching?

4 :
A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply)

5 :
A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

6 :
A nurse is assessing a client who has a new diagnosis of SLE (Lupus). Which of the following findings should the nurse expect?

7 :
A nurse is providing teaching for a client who has stage 3 HIV disease (AIDS). Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

8 :
Which of the following are common signs or symptoms of GI bleeding? (Select all that apply)

9 :
Your patient had an open colon resection a week ago and developed a subsequent infection of their surgical incision. Now the patient's blood pressure has been dropping for the past 2 hours and is currently 89/65. What type of shock is the patient experiencing?

10 :
Which of the following is are appropriate nursing interventions to ensure the safety of a patient who is receiving Total Parenteral Nutrition (TPN)? (Select all that apply)