Butterfly Effect
Which clinical manifestation is most specific for SLE and helps distinguish it from other autoimmune disorders?
A. Weight gain and cold intolerance
B. Butterfly rash across the cheeks and nose
C. Muscle wasting in the lower limbs
D. Hardening of the skin and digital ulcers
B. Butterfly rash across the cheeks and nose
The “butterfly rash” is a hallmark of SLE
A client with newly diagnosed RA asks why their immune system is “attacking itself.” Which explanation by the nurse is most accurate?
A. “Your body is producing antibodies against its own IgG, forming complexes that damage the joints.”
B. “Your immune system fails to recognize viral proteins and causes chronic inflammation.”
C. “The immune complexes are limited to muscles and connective tissue only.”
D. “The antigens attach to red blood cells causing hemolysis.”
A. “Your body is producing antibodies against its own IgG, forming complexes that damage the joints.”
Autoantibodies attack IgG forming immune complexes that damage synovial tissue
Which lab result would cause the nurse to hold the next dose of methotrexate?
A. WBC = 4.5 K/µL
B. ALT = 25 U/L
C. Platelets = 75 K/µL
D. ESR = 30 mm/hr
C. Platelets = 75 K/µL
Platelet count < 100 K/µL → risk for bleeding from bone-marrow suppression
Which statement by a client taking prednisone for SLE requires follow-up?
A. “I’ll take my dose in the morning with food.”
B. “I’ll stop taking it once I feel better.”
C. “I’ll monitor for signs of infection.”
D. “I’ll avoid crowds and sick people.”
B. “I’ll stop taking it once I feel better.”
Stopping abruptly can cause adrenal crisis
A client on methotrexate develops a fever and sore throat. What should the nurse do first?
A. Document findings and reassess in 2 hours
B. Notify the provider immediately
C. Administer acetaminophen for fever
D. Encourage fluid intake and rest
B. Notify the provider immediately
Methotrexate causes bone marrow suppression; infection requires immediate provider notification
Which laboratory finding supports the diagnosis of SLE?
A. Negative ANA titer
B. Elevated anti-Smith antibodies
C. Decreased ESR
D. Elevated hematocrit and RBC count
B. Elevated anti-Smith antibodies
Positive anti-Smith and anti-DNA antibodies confirm diagnosis
Which clinical finding supports Stage III (severe) rheumatoid arthritis?
A. No joint deformities but mild muscle atrophy
B. Osteoporosis visible on x-ray only
C. Joint deformity and bone destruction
D. Fibrous ankylosis and total immobility
C. Joint deformity and bone destruction
Stage III = bone and cartilage destruction, deformity, and atrophy
Before administering a TNF inhibitor, which action must the nurse complete?
A. Obtain a pregnancy test
B. Check temperature only
C. Obtain a TB test and chest x-ray
D. Restrict fluids for 12 hours
C. Obtain a TB test and chest x-ray
TB screening prevents reactivation while immunosuppressed
A client on hydroxychloroquine needs which critical follow-up?
A. Eye exams every 6 months
B. Liver function every week
C. EKG every 3 months
D. Chest x-ray every year
A. Eye exams every 6 months
Risk for retinal toxicity; ophthalmologic monitoring is essential
After several months of therapy, which finding best indicates that treatment for SLE is effective?
A. Persistent proteinuria
B. Decrease in ESR and fatigue
C. Increased frequency of rashes
D. New onset of headaches
B. Decrease in ESR and fatigue
Lower ESR and improved energy show decreased inflammation and improved disease control
The nurse should include which teaching for a client newly diagnosed with SLE?
A. “Avoid all vaccines to prevent triggering flares.”
B. “You should limit exposure to ultraviolet light and use sunscreen daily.”
C. “Increase estrogen-based medications to prevent fatigue.”
D. “Reduce your fluid intake to prevent kidney strain.”
B. “You should limit exposure to ultraviolet light and use sunscreen daily.”
Sun and UV exposure trigger flares; daily sunscreen use is essential
Which statement by the client indicates a need for further teaching about methotrexate?
A. “I’ll have my blood work monitored for liver damage.”
B. “I’ll avoid becoming pregnant while taking this medication.”
C. “It’s safe to take my herbal supplements with this medication.”
D. “This drug helps slow down the progression of my disease.”
C. “It’s safe to take my herbal supplements with this medication.”
Methotrexate interacts with many supplements; avoid hepatotoxic or unverified herbal products
A client taking both an NSAID and prednisone reports black, tarry stools. What’s the nurse’s priority?
A. Reassure that this is expected
B. Administer antacid
C. Hold medications and notify the provider
D. Encourage more fluids
C. Hold medications and notify the provider
Both drugs can cause GI bleeding; stop and report immediately
Which teaching point is most important for SLE clients taking NSAIDs long-term?
A. “Take on an empty stomach for best absorption.”
B. “Stop taking them if you develop tinnitus or GI bleeding.”
C. “Double the dose during pain flares.”
D. “It’s safe to combine with herbal anti-inflammatory teas.”
B. “Stop taking them if you develop tinnitus or GI bleeding.”
Tinnitus = toxicity; melena = GI bleed
A 54-year-old client with rheumatoid arthritis is taking methotrexate and prednisone. The nurse reviews the morning labs and notes:
WBC: 2.8 K/µL
ALT: 62 U/L
Temperature: 100.9 °F (38.3 °C)
ESR: 68 mm/hr
Which nursing action is most appropriate?
A. Continue medications and encourage oral fluids
B. Hold methotrexate and notify the health-care provider
C. Administer scheduled dose of prednisone immediately
D. Document findings and recheck temperature in four hours
B. Hold methotrexate and notify the health-care provider
Low WBC + fever = possible infection from methotrexate-induced bone-marrow suppression. Elevated ALT shows hepatotoxicity. The nurse should withhold methotrexate and notify the provider for further evaluation and possible dose adjustment
Which assessment finding requires immediate nursing intervention in a client with SLE?
A. Fatigue and photosensitivity
B. Mild alopecia
C. New onset of confusion and headache
D. Mild peripheral edema
C. New onset of confusion and headache
CNS involvement (confusion, headache) signals life-threatening flare
The nurse plans care around a client’s complaint of morning stiffness. Which intervention best helps the client perform ADLs?
A. Encourage a cool shower on awakening
B. Administer NSAID immediately on rising
C. Encourage sitting in a warm shower or soaking hands in warm water
D. Apply splints before bedtime and leave them on all day
C. Encourage sitting in a warm shower or soaking hands in warm water
Warmth reduces stiffness and improves ADLs
Which medication combination requires nurse caution due to additive toxicity?
A. Methotrexate + Acetaminophen
B. NSAID + Aspirin
C. Hydroxychloroquine + Prednisone
D. Leflunomide + Methotrexate
D. Leflunomide + Methotrexate
Both are hepatotoxic; monitor LFTs closely
Which statement indicates the SLE client on corticosteroids and immunosuppressants needs more teaching?
A. “I’ll ask before getting any live vaccines.”
B. “I should get the flu and pneumonia vaccines.”
C. “I’ll avoid people recently vaccinated with live viruses.”
D. “Vaccines are unsafe for everyone with lupus.”
D. “Vaccines are unsafe for everyone with lupus.”
Only live vaccines are avoided; inactivated ones are recommended
During an acute SLE flare, which problem requires the nurse’s immediate attention?
A. Client expressing feelings of hopelessness
B. Temperature 102°F and increased WBC count
C. Photosensitivity rash
D. Decreased appetite and mild nausea
B. Temperature 102°F and increased WBC count
Fever and leukocytosis indicate infection, the leading cause of death in SLE
Which nursing diagnosis has highest priority for a client experiencing an acute SLE exacerbation?
A. Disturbed body image
B. Impaired skin integrity
C. Fatigue
D. Risk for infection
D. Risk for infection
Immunosuppression and corticosteroid therapy increase infection risk
A client on TNF-inhibitor therapy for RA should be instructed to:
A. Receive all live vaccines before each dose
B. Expect mild fever and rash as normal effects
C. Report any signs of infection to the provider immediately
D. Double the next dose if a previous dose was missed
C. Report any signs of infection to the provider immediately
TNF-inhibitors suppress immunity; infection must be reported immediately
A client with RA is prescribed prednisone for inflammation control. Which nursing instruction is most appropriate?
A. “Take the medication on an empty stomach each morning.”
B. “You can stop the medication as soon as your pain improves.”
C. “Take the dose in the morning with food and taper off gradually.”
D. “Double your dose if your joints become more painful.”
C. “Take the dose in the morning with food and taper off gradually.”
Corticosteroids should be taken with food (to prevent GI upset), in the morning (to mimic natural cortisol release), and never stopped abruptly, tapering prevents adrenal insufficiency
A client with rheumatoid arthritis is prescribed etanercept (Enbrel), a TNF-inhibitor. Which instruction should the nurse include in the teaching plan?
A. “You can give the injection even if you have a mild cold.”
B. “Report any signs of infection such as fever, cough, or open sores immediately.”
C. “Store the pre-filled syringe at room temperature.”
D. “Live vaccines will help prevent infections while on this drug.”
B. “Report any signs of infection such as fever, cough, or open sores immediately.”
TNF inhibitors suppress immune function, greatly increasing infection risk. Clients must report any signs of infection and avoid live vaccines while on therapy
A 39-year-old female with both SLE and RA reports chest pain, dyspnea, and increased joint pain. Current meds: prednisone, hydroxychloroquine (Plaquenil), and etanercept (Enbrel).
Assessment findings: shallow respirations, O₂ sat 88%, diminished breath sounds at bases, WBC 3.1 K/µL.
What is the nurse’s priority action?
A. Administer the next scheduled dose of etanercept
B. Notify the provider and prepare for diagnostic testing
C. Instruct the client to use an incentive spirometer hourly
D. Document findings and continue to monitor respiratory rate
B. Notify the provider and prepare for diagnostic testing
Chest pain and hypoxia in an SLE/RA patient on immunosuppressants suggest pleuritis or pleural effusion, not infection or cardiac ischemia. The nurse must notify the provider immediately and anticipate diagnostic imaging or thoracentesis. Continuing TNF-inhibitor therapy could worsen infection or inflammation