in which condition is the butterfly rash most commonly seen
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HESI PN Exit Exam 2024 Quizlet

1. In which condition is the 'butterfly rash' most commonly seen?

Correct answer: A

Rationale: The correct answer is A: Systemic lupus erythematosus (SLE). The 'butterfly rash' across the cheeks and nose is a classic sign of SLE, an autoimmune disease. This rash is a key dermatological manifestation of SLE, often triggered or worsened by exposure to sunlight. Choices B, C, and D are incorrect because the 'butterfly rash' is not commonly associated with rheumatoid arthritis, psoriasis, or dermatomyositis.

2. When documenting information in a client's medical record, what should the nurse do?

Correct answer: D

Rationale: When documenting information in a client's medical record, the nurse should end each entry with their signature and title. This practice is crucial for legal and professional standards compliance as it ensures that the documentation is attributable to the responsible individual. Choices A, B, and C are incorrect because while crossing out errors, using a black ink pen, and leaving a blank line before each entry are good practices, they are not as critical as ensuring each entry is signed and titled by the nurse for accountability and traceability.

3. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?

Correct answer: A

Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.

4. A nurse is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the nurse document in the medical record?

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, or the repetition of words, is indicative of disturbed thought processes, a common symptom in clients with schizophrenia. Choice A (Altered thought processes) is a more appropriate term than 'Disturbed thought processes' to describe the issue of echolalia. Choice B (Impaired social interaction) is not the best option in this scenario as echolalia is not primarily a social interaction issue. Choice C (Risk for self-directed violence) is not directly related to the symptom described in the question, which is echolalia, indicating a disturbance in thought processes.

5. Which electrolyte imbalance is most commonly associated with seizures?

Correct answer: A

Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.

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