Answers
Secondary infections are a major concern with SLE clients due to the use of corticosteroids and
chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections
should be reported immediately. ✔️✔️A client is recently diagnosed with systemic lupus
erythematosus (SLE) and the registered nurse (RN) is assessing for common complications.
Which symptom should the RN instruct the client to report immediately?
· Fever related to infection.
· Weight loss and anorexia.
· Depressed mood.
· Break in tissue integrity.
· A fracture that bends or splinters part of the bone.
An incomplete fracture occurs when part of the bone is splintered (broken) and it has not gone
completely through the thickness of the bone. ✔️✔️A male client is admitted after falling from
his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the
humerus. The family ask the RN what this means. Which explanation by the nurse accurately
describes the client's fracture?
· Straight fracture line that is also a simple, closed fracture.
· Nondisplaced fracture line that wraps around the bone.
· A complete fracture that also punctures the skin.
,· A fracture that bends or splinters part of the bone.
· Polydipsia.
A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most
clients compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur
when there has been damage or injury to the pituitary gland or hypothalamus as a result of head
trauma, tumor or an illness such as meningitis. This damage interrupts the ADH production,
storage and release causing the excessive urination and thirst. ✔️✔️The registered nurse (RN)
is caring for a client who has a closed head injury from a motor vehicle collision. Which finding
would indicate to the nurse that the client is at risk for diabetes insipidus (DI)?
· High fever.
· Low blood pressure.
· Muscle rigidity.
· Polydipsia.
· Prepare the client for chest x-ray at the bedside.
A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung
expansion has been maintained after its removal. ✔️✔️The registered nurse (RN) is assisting
the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the
highest priority and should be anticipated by the RN after the removal of the chest tube?
· Prepare the client for chest x-ray at the bedside.
· Review arterial blood gases after removal.
, · Elevate the head of bed to 45 degrees.
· Assist with disassembling the drainage system.
· Serum troponin.
Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is
more specific than CK-MB. ✔️✔️A client with chest pain, dizziness, and vomiting for the last
2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac
biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced
myocardial damage?
· Creatine Kinase (CK-MB).
· Serum troponin.
· Myoglobin.
· Ischemia modified albumin.
· African American women.
Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs and has shown
familial tendency due to multiple genes that together increase the susceptibility of developing the
disease. In research studies it occurs more commonly in African American women (10-80 out of
100,000); compare to Caucasian women of the United States (8 out of 100,000). ✔️✔️A
female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN)
that she does not understand why she has this. When teaching the client, the RN should include
that sarcoidosis most commonly occurs with which ethnic group of women?
· African American women.