NCLEX RN Practice Question # 484
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Nclex Practice Questions
Autoimmune Disease (NCLEX Review)
Description
- Body is unable to recognize its own cells as a part of itself.
- Autoimmune disease can affect collagenous tissue.
Systemic lupus erythematosus (SLE)
Description
- Chronic, progressive, systemic inflammatory disease that can cause major organs and systems to fail
- Connective tissue and fibrin deposits collect in blood vessels on collagen fibers and on organs.
- The deposits lead to necrosis and inflammation in blood vessels, lymph nodes, gastrointestinal tract, and pleura.
- No cure for the disease is known but remissions are frequently experienced by clients who manage their care well.
Causes
- The cause of SLE is unknown, but is believed to be a defect in immunological mechanisms, with a genetic origin.
- Precipitating factors include medications, stress, genetic factors, sunlight or ultraviolet light, and pregnancy.
- Discoid lupus erythematosus is possible with some medications but totally disappears after the medication is stopped; the only manifestation is the skin rash that occurs in lupus.
Assessment
- Assess for precipitating factors.
- Erythema butterfly or rash of the face (malar)
- Dry, scaly, raised rash on the face or upper body
- Fever
- Weakness, malaise, and fatigue
- Anorexia
- Weight loss
- Photosensitivity
- Joint pain
- Erythema of the palms
- Anemia
- Positive antinuclear antibody (ANA) test and lupus erythematosus (LE) preparation
- Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level
Interventions
- Monitor skin integrity and provide frequent
- Instruct the client to clean the skin with a mild soap, avoiding harsh and perfume substances.
- Assist with the use of ointments and creams for the rash as prescribed.
- Identify factors contributing to fatigue.
- Administer iron, folic acid, or vitamin supplements as prescribed if anemia occurs.
- Provide a high-vitamin and high-iron diet.
- Provide a high-protein diet if there is no evidence of kidney disease.
- Instruct in measures to conserve energy, such as pacing activities and balancing rest with exercise.
- Administer topical or systemic corticosteroids, salicylates, and nonsteroidal antiinflammatory drugs as prescribed for pain and inflammation.
- Administer medications to decrease the
- inflammatory response as prescribed.
- Instruct the client to avoid exposure to sunlight and ultraviolet light.
- Monitor for proteinuria and red cell casts in the urine.
- Monitor for bruising, bleeding, and injury.
- Assist with plasmapheresis as prescribed to remove autoantibodies and immune complexes from the blood before organ damage occurs.
- Monitor for signs of organ involvement such as pleuritis, nephritis, pericarditis, coronary artery disease, hypertension, neuritis, anemia, and peritonitis.
- Note that lupus nephritis occurs early in the disease process.
- Provide supportive therapy as major organs become affected.
- Provide emotional support and encourage the client to verbalize feelings.
- Provide information regarding support groups and encourage the use of community resources. For the client with SLE,