Lupus
A nurse is reviewing laboratory results for a client suspected of having Systemic Lupus Erythematosus. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are elevated. Which interpretation by the nurse is most accurate?
A. These findings confirm the diagnosis of SLE
B. These findings indicate acute infection only
C. These findings reflect inflammation but are not specific to SLE
D. These findings rule out autoimmune disease
Correct Answer: C
Rationale: ESR and CRP are nonspecific inflammatory markers. While elevated in SLE, they do not confirm diagnosis. According to NCSBN clinical judgment, the nurse must avoid premature conclusions and recognize that additional tests (e.g., ANA, anti-dsDNA) are required.
A nurse is caring for a client with Systemic Lupus Erythematosus who has a malar rash and reports worsening redness after being outdoors. Which nursing intervention is most appropriate?
A. Encourage daily sun exposure to improve vitamin D levels
B. Apply heat packs to the face
C. Educate the client to use sunscreen and avoid direct sunlight
D. Wash the face frequently with antibacterial soap
Correct Answer: C
Rationale: Photosensitivity is a key manifestation of SLE. The nurse analyzes the cause of symptom exacerbation and implements trigger avoidance (UV exposure) to reduce flares.
A nurse is caring for a client with Systemic Lupus Erythematosus who is prescribed a 24-hour urine collection. Which statement best reflects the purpose of this test?
A. To confirm the diagnosis of lupus
B. To evaluate kidney involvement by measuring protein excretion
C. To assess liver function
D. To determine electrolyte imbalance only
Correct Answer: B
Rationale: The 24-hour urine test is used to quantify protein loss, which helps assess renal involvement (lupus nephritis). It does not diagnose SLE but evaluates organ damage and disease progression, requiring the nurse to analyze the purpose beyond surface-level testing.
A nurse is assessing a client who is concerned about developing skin cancer. Which finding represents the strongest risk factor?
A. Uses sunscreen SPF 30 when outdoors
B. Works indoors most of the time
C. History of severe blistering sunburns during childhood
D. Eats a diet high in antioxidants
Correct Answer: C
Rationale: A history of severe sunburns, especially in childhood, significantly increases lifetime risk for skin cancer due to DNA damage from ultraviolet (UV) radiation. The nurse must analyze cumulative UV exposure risk, not protective behaviors.
A nurse is assessing a client with a circular, erythematous, pruritic rash with a well-defined scaly border on the left forearm. The healthcare provider prescribes topical miconazole. Which statement by the client indicates a need for further teaching?
A. "I will apply the cream for two weeks after the rash appears to be gone." B. "I should keep the area covered with a thick dressing to prevent spreading." C. "I will avoid sharing my towels or clothing with my family members." D. "I need to dry the skin thoroughly after bathing before applying the medication."
Answer: B. "I should keep the area covered with a thick dressing to prevent spreading."
Rationale: Analysis: Fungal infections (tinea corporis) thrive in warm, moist environments. The area should be kept clean and dry; occlusive or thick dressings should be avoided because they trap moisture and heat, potentially worsening the infection.
A nurse is assessing a client suspected of having Systemic Lupus Erythematosus. Which cluster of findings should the nurse recognize as most consistent with this condition?
A. Productive cough, fever, and chest pain
B. Butterfly rash, joint pain, and photosensitivity
C. Weight gain, bradycardia, and dry skin
D. Polyuria, polydipsia, and blurred vision
Correct Answer: B
Rationale: SLE commonly presents with malar (butterfly) rash, arthralgia, and photosensitivity. The nurse must recognize patterns of multisystem involvement
A client with Systemic Lupus Erythematosus reports fatigue and joint stiffness. Which nursing recommendation demonstrates appropriate care planning?
A. Encourage strict bed rest to prevent joint damage
B. Alternate rest periods with activity and use energy conservation techniques
C. Avoid all physical activity during symptom-free periods
D. Increase high-impact exercise to improve joint mobility
Correct Answer: B
Rationale: The nurse must balance activity and rest. Energy conservation helps manage fatigue while maintaining joint function—reflecting analysis of symptom patterns and functional impact.
A nurse is reviewing laboratory results for a client suspected of having Systemic Lupus Erythematosus. The client has a positive antinuclear antibody (ANA) test. Which interpretation by the nurse is most appropriate?
A. A positive ANA confirms the diagnosis of lupus
B. A positive ANA indicates an autoimmune process but is not specific to lupus
C. A positive ANA rules out other autoimmune diseases
D. A negative ANA confirms lupus
Correct Answer: B
Rationale: ANA is highly sensitive but not specific for SLE. The nurse must analyze the result within the broader clinical picture and recognize that additional antibody testing.
A nurse is teaching a client about skin cancer prevention. Which client behavior indicates the highest risk for developing skin cancer?
A. Wearing long sleeves while gardening
B. Using tanning beds regularly
C. Applying sunscreen before swimming
D. Wearing a wide-brimmed hat outdoors
Correct Answer: B
Rationale: Tanning beds emit intense UV radiation, which directly damages skin cell DNA and significantly increases skin cancer risk. The nurse analyzes environmental exposure patterns that increase risk.
The nurse is reviewing the medical records of four assigned clients. Which client is at the highest risk for developing a localized Candida albicans (candidiasis) infection of the skin?
A. A 22-year-old athlete who wears synthetic compression shorts during long runs.
B. A 45-year-old client who recently completed a 10-day course of amoxicillin.
C. A 60-year-old client with a history of basal cell carcinoma on the nose.
D. A 78-year-old client who uses an electric shaver and moisturizing aftershave.
Answer: B. A 45-year-old client who recently completed a 10-day course of amoxicillin.
Rationale: Analysis: Lewis emphasizes that Candida albicans is an opportunistic pathogen. High-risk factors include immunosuppression and the use of broad-spectrum antibiotics, which disrupt the normal bacterial flora that usually keeps yeast growth in check.
A client with known Systemic Lupus Erythematosus reports new symptoms. Which finding requires immediate follow-up?
A. Fatigue and joint stiffness
B. Facial rash after sun exposure
C. Pleuritic chest pain and shortness of breath
D. Mild hair thinning
Correct Answer: C
Rationale:
Pleuritic chest pain and dyspnea may indicate serositis or pleural effusion, which can compromise respiratory status. Prioritization emphasizes life-threatening complications first.
A nurse is caring for a client with Systemic Lupus Erythematosus who is experiencing joint pain and inflammation. The client is prescribed NSAIDs. Which assessment finding requires the nurse to take further action?
A. Reports mild relief of joint pain
B. Complaints of epigastric discomfort
C. Increased ability to perform daily activities
D. Slight decrease in joint stiffness
Correct Answer: B
Rationale:
NSAIDs can cause gastrointestinal irritation and bleeding. The nurse must analyze symptoms and recognize early signs of complications, requiring follow-up or medication adjustment.
A nurse is caring for a client with Systemic Lupus Erythematosus who suddenly develops a generalized seizure. Which nursing action is the priority?
A. Insert an oral airway to prevent tongue biting
B. Turn the client to the side and protect the head
C. Restrain the client’s arms and legs
D. Administer prescribed antiepileptic medication immediately
Correct Answer: B. Turn the client to the side and protect the head
Rationale: The priority during an active seizure is maintaining airway and preventing injury. Side-lying positioning reduces aspiration risk, and protecting the head prevents trauma.
A nurse is caring for a client with a suspicious pigmented lesion. The provider suspects skin cancer. Which diagnostic test is most definitive for confirming the diagnosis?
A. Dermoscopy examination
B. Skin biopsy
C. Complete blood count (CBC)
D. Visual inspection using the ABCDE rule
Correct Answer: B
Rationale: A skin biopsy is the gold standard diagnostic test for confirming skin cancer because it allows histologic examination of cells. The nurse must differentiate between screening tools (dermoscopy, visual exam) and definitive diagnosis (biopsy).
A nurse is caring for a 72-year-old client diagnosed with herpes zoster (shingles) on the right thoracic dermatome. The client reports a pain level of 9 out of 10 and is observed scratching the vesicles. Which nursing action is the priority to include in the plan of care?
A. Apply wet-to-dry dressings to the affected area every 4 hours.
B. Administer prescribed acyclovir within 72 hours of rash onset.
C. Encourage the client to wear tight-fitting cotton clothing.
D. Maintain the client on droplet precautions until the lesions have crusted.
Answer: B. Administer prescribed acyclovir within 72 hours of rash onset.
Rationale: Analysis: Antiviral agents (like acyclovir, famciclovir, or valacyclovir) are the priority because they reduce the severity of the infection and the risk of postherpetic neuralgia, provided they are started within 72 hours of the rash appearing.
The nurse reviews the following data in a client with Systemic Lupus Erythematosus: Joint pain, Fever, Fatigue, Malar rash. What is the nurse’s best interpretation?
A. The client is experiencing a lupus flare
B. The client has a bacterial infection
C. The client is improving
D. The findings are unrelated
Correct Answer: A
Rationale: This combination reflects systemic inflammatory activity, consistent with a flare. The nurse integrates multiple cues rather than isolating a single symptom.
A client with Systemic Lupus Erythematosus is prescribed corticosteroids for a disease flare. Which finding indicates the need for immediate nursing intervention?
A. Increased appetite
B. Weight gain
C. Fever and sore throat
D. Mild mood changes
Correct Answer: C
Rationale: Corticosteroids suppress the immune system, increasing infection risk. Fever and sore throat may indicate infection and require prompt evaluation.
A nurse is preparing to administer methotrexate to a client with Systemic Lupus Erythematosus. Which finding should the nurse question before giving the medication?
A. White blood cell count of 2,500/mm³
B. Reports of mild joint pain
C. Blood pressure of 128/78 mm Hg
D. Complaint of fatigue
Correct Answer: A. White blood cell count of 2,500/mm³
Rationale: Methotrexate is an immunosuppressant that can cause bone marrow suppression. A low WBC indicates increased infection risk and is a contraindication or reason to hold the medication.
This requires the nurse to analyze lab data and identify unsafe conditions before administration.
A nurse is assessing a client for possible skin cancer. Which findings should the nurse identify as concerning for malignancy? (Select all that apply.)
A. Mole with irregular, notched borders
B. Symmetrical, evenly colored brown mole
C. Lesion that bleeds easily and does not heal
D. Mole with multiple shades of brown, black, and tan
E. Small freckle that has remained unchanged for years
F. Lesion that is increasing in diameter over several months
Correct Answers: A, C, D, F
Rationale (Analysis – Cue Recognition using ABCDE principles)
The nurse must analyze lesion characteristics associated with malignancy:
The nurse is providing discharge teaching to a client diagnosed with verruca vulgaris on the plantar surface of the foot. Which statement by the client indicates a correct understanding of the condition and its treatment?
A. "Once these warts are removed with liquid nitrogen, they will not return."
B. "I should avoid walking barefoot in public locker rooms to prevent spreading."
C. "The virus is deeply systemic, so I will need to take oral antibiotics for a month.
" D. "I should use a pumice stone to vigorously scrub the warts off tonight."
Answer: B. "I should avoid walking barefoot in public locker rooms to prevent spreading."
Rationale: Analysis: Verruca vulgaris (common warts) is caused by the Human Papillomavirus (HPV). Lewis notes that the virus is contagious and can be spread to other parts of the body or to other people through direct contact or contaminated surfaces like moist floors.
A nurse is caring for a client with a recent diagnosis of Systemic Lupus Erythematosus. The nurse reviews the following assessment data: Blood pressure: 148/92 mm Hg, urinalysis: 3+ protein, Reports of facial swelling in the morning, complaints of joint pain and fatigue
Based on this information, which finding is the strongest indicator of renal involvement requiring further evaluation?
A. Reports of joint pain
B. Elevated blood pressure
C. Proteinuria on urinalysis
D. Facial swelling
Correct Answer: C. Proteinuria on urinalysis
Proteinuria is the most specific indicator of kidney involvement (lupus nephritis) and reflects damage to the glomeruli.
The nurse is teaching a client with Systemic Lupus Erythematosus about prescribed immunosuppressant therapy. Which statement by the client indicates a need for further teaching?
A. “I should avoid people who are sick.”
B. “I will report any signs of infection.”
C. “I can receive live vaccines while on this medication.”
D. “I need regular blood tests while taking this drug.”
Correct Answer: C
Rationale: Clients on immunosuppressants should avoid live vaccines due to infection risk. The nurse analyzes understanding and identifies unsafe statements.
A nurse is providing discharge teaching to a client with Systemic Lupus Erythematosus who is taking immunosuppressive therapy. The client asks why they should avoid live vaccines. Which response by the nurse is most accurate?
A. “Live vaccines will not work in people with lupus.”
B. “Live vaccines can cause severe infection in immunosuppressed clients.”
C. “Live vaccines increase antibody production too quickly.”
D. “Live vaccines are only avoided because of allergies.”
Correct Answer: B
Rationale: Clients with SLE often take immunosuppressive medications, which reduce the body’s ability to fight infections. Live attenuated vaccines contain weakened organisms that can replicate, leading to serious infection in immunocompromised clients.
A client undergoes excision of a malignant skin lesion. Which nursing action is most appropriate in post-treatment care to promote healing and prevent complications?
A. Encourage sun exposure to improve vitamin D levels
B. Keep the wound clean and monitor for signs of infection
C. Apply heat packs to increase circulation to the site
D. Massage the surgical site daily to prevent scarring
Correct Answer: B. Keep the wound clean and monitor for signs of infection
Rationale: Post-surgical care for skin cancer removal focuses on infection prevention and wound healing. The nurse must prioritize protecting the surgical site and monitoring for complications, rather than interventions that could damage tissue or delay healing.
The nurse is providing education to a parent whose child has been diagnosed with pediculosis capitis. Which instruction is essential to include to prevent a recurrence of the infestation?
A. "Wash all bed linens and recently worn clothes in cold water and air dry."
B. "Treat all family members with pediculicide shampoo regardless of symptoms."
C. "Use a fine-toothed comb to remove nits from the hair shaft after treatment."
D. "Vacuum all carpets and upholstered furniture daily for the next 30 days."
Answer: C. "Use a fine-toothed comb to remove nits from the hair shaft after treatment."
Rationale: Analysis: Lewis specifies that the removal of nits (eggs) is a critical step in managing pediculosis because if nits remain, they can hatch and cause a re-infestation even after the adult lice are killed.