Difficulty: Medium
Average Score: 76%
Simulated
Passage / Scenario
The following scenario applies to the next 6 itemsThe nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 6 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
ÔÇó The client was directly admitted to the intensive care unit for observation and medical management. ÔÇó Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The nurse teaches the client self-care practices for systemic lupus erythematosus (SLE). Which two (2) client statements indicate effective understanding?
Correct answer
B,D
Rationale
Wearing long sleeves and a large-brimmed hat (B) and using cosmetics with moisturizers and sun protectors (D) indicate understanding of photoprotection, crucial for SLE to prevent rash exacerbation. Limiting sun exposure to 45 minutes (A) is too specific and risky, antibacterial soap (C) is unnecessary, and avoiding all vaccines (E) is incorrect as some are safe.