the nurse is most concerned about which of these findings in a client with systemic lupus erythematous

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

A. The client reports chronic fatigue
B. The client has a butterfly rash
C. Blood pressure of 126/85 mm Hg
D. Urine output of 20 mL/hour

Correct answer: D

Rationale:

2. What are signs of hearing loss? (Select all that apply)

A. Presence of cerumen
B. Presence of cerumen
C. Tinnitus
D. Frequent asking of others to repeat statements

Correct answer: C

Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.

3. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

A. Maintain the client's blood pressure
B. Call a chaplain
C. Provide the spouse a chair
D. Ask the client's spouse to explain what happened

Correct answer: A

Rationale:

4. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?

A. Applying moisturizer to dry areas of the skin
B. Massaging the client's reddened shoulders and heels
C. Cleansing the skin routinely after soiling occurs
D. Using a Hoyer lift for all transfers

Correct answer: B

Rationale:

5. What device would be best to use for a client who is immobile?

A. Standing assist device
B. A mechanical lift
C. Transfer board
D. Gait belt

Correct answer: B

Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.