# A 45-year-old client with systemic lupus erythematosus (SLE) is admitted to the medical unit with a lupus flare. The client reports severe joint pain, facial rash, and fatigue. Laboratory results show elevated anti-dsDNA antibodies and decreased complement levels (C3 and C4). Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540851 > language: ko > subject: Adult Health ## 문제 A 45-year-old client with systemic lupus erythematosus (SLE) is admitted to the medical unit with a lupus flare. The client reports severe joint pain, facial rash, and fatigue. Laboratory results show elevated anti-dsDNA antibodies and decreased complement levels (C3 and C4). Which nursing intervention should be the priority? ## 보기 1. Encourage increased physical activity to prevent joint stiffness 2. Apply heat therapy to inflamed joints for pain relief 3. Administer aspirin for anti-inflammatory effects 4. Implement strict infection control precautions **✔ 정답** **정답: 4** ## 해설 Infection control is the priority due to immune compromise from elevated anti-dsDNA and low complement levels during an SLE flare. Other options are less critical: activity may worsen fatigue, heat therapy is supportive, and aspirin is not first-line for SLE inflammation. ## 심화 해설 Understanding the Priority: Infection Risk in SLE Flare The client is experiencing an active lupus flare, evidenced by severe joint pain, facial rash, fatigue, elevated anti-dsDNA antibodies, and decreased complement levels (C3 and C4). While addressing pain and fatigue is important, the priority nursing intervention is to implement strict infection control precautions. This is because the combination of the disease process and its primary medical treatment creates a state of significant immunocompromise, making infection the most immediate life-threatening risk. Pathophysiology and Clinical Rationale The laboratory findings provide direct evidence for this prioritization. Decreased complement levels, specifically C3 and C4, are a hallmark of active SLE. These proteins are a critical part of the innate immune system; their consumption during immune complex formation in a flare leads to a functional deficiency. This directly impairs the body's ability to opsonize and clear pathogens, creating a state of secondary immunodeficiency. Furthermore, the cornerstone of managing a severe lupus flare, as highlighted in the British Society for Rheumatology guideline, involves suppressing systemic disease activity to prevent organ damage [1]. This is typically achieved with high-dose corticosteroids and other immunosuppressants like cyclophosphamide or mycophenolate mofetil. These therapies further suppress the already compromised immune response, dramatically elevating the client's susceptibility to bacterial, viral, and opportunistic infections. A simple infection can rapidly progress to sepsis in this vulnerable population, making prevention the absolute priority. Analyzing the Incorrect Options The other options are not the priority because they either pose a direct risk to the client or address a lower-level need. - Option 1 (Encourage increased physical activity): This is contraindicated during an acute flare. The client is experiencing severe fatigue and joint inflammation. Rest is essential to conserve energy and reduce the metabolic demands on an already stressed body. Increased activity would exacerbate inflammation and pain. - Option 2 (Apply heat therapy to inflamed joints): While pain relief is a valid nursing concern, the choice of heat therapy is incorrect for acute inflammation. Heat can increase blood flow and worsen the inflammatory process in already acutely inflamed joints. Cold therapy would be more appropriate for its vasoconstrictive and analgesic effects on localized inflammation, but even this does not address the life-threatening risk of infection. - Option 3 (Administer aspirin for anti-inflammatory effects): Aspirin is not a first-line treatment for the systemic inflammation of a lupus flare. It is insufficient to control the disease activity and does not address the underlying autoimmune dysfunction. Management requires potent immunosuppressive agents to achieve the key aim of suppressing systemic disease activity and preventing organ damage [1]. More critically, SLE patients may have concurrent lupus nephritis or thrombocytopenia, where aspirin could increase the risk of renal impairment and bleeding. Clinical Application and Nursing Practice For an SLE client admitted with a flare, your clinical reasoning must immediately connect the lab values (low complements, high anti-dsDNA) and the intended medical therapy (immunosuppression) to the highest risk: infection. Strict infection control precautions, including meticulous hand hygiene, protective isolation if neutropenic, and vigilant monitoring for subtle signs of infection (as corticosteroids can mask fever), are the most critical actions to prevent morbidity and mortality from what is a preventable complication. This aligns directly with the guideline's emphasis on preventing organ damage, which includes damage from overwhelming sepsis [1].References (research sources) - [1]The 2026 British Society for Rheumatology guideline for the management of children, young people and adults with systemic lupus erythematosus.GuidelineMd Yusof MY, Smith EMD, Lythgoe H, Psarras A, Armon K, Beresford MW, Cherry L, Corp N, Edwards CJ, Felix L, Flora K, Gilman R, Griffiths B, Gordon C, Isenberg D, Jordan N, Kinsey D, Kaul A, Laws PM, Lightstone L, Mallen CD, Marks SD, Maxwell N, McLaren Z, Moraitis E, Nash C, Pepper RJ, Pilkington C, Rostron H, Skeates J, Skeoch S, Tremarias D, van der Windt DA, Wincup C, Zoma A, Lanyon P, Vital EM, British Society for Rheumatology Guidelines Steering Group members . (2026) · DOI: 10.1093/rheumatology/keag223 ## 임상 시나리오 Clinical Priority: Infection Risk in an SLE Flare A 45-year-old client with SLE is admitted with an active flare (severe joint pain, malar rash, fatigue). Labs show elevated anti-dsDNA and low C3/C4. The combination of disease-driven complement depletion and the imminent initiation of high-dose corticosteroids/immunosuppressants creates a profound immunocompromised state. The immediate, overarching nursing priority is safety from infection, as sepsis is the leading cause of mortality in this population. Nursing Actions for Infection Control: - **Strict Hand Hygiene:** Ensure all staff, visitors, and the client perform hand hygiene before and after contact. - **Protective Environment:** Place the client in a private room if possible. Restrict visitors with any signs of infection. No fresh flowers or live plants. - **Monitoring:** Vigilantly assess for subtle signs of infection (low-grade fever, tachycardia) as corticosteroids can mask fever and inflammation. Monitor WBC count with differential. - **Skin Integrity:** Perform meticulous skin assessment and care, as the malar rash and potential skin fragility from steroids increase portals of entry for pathogens. - **Invasive Line Care:** Use strict aseptic technique for any IV lines or catheters. Advocate for early removal of unnecessary lines. Symptom Management (Non-Priority but Essential): - **Pain & Fatigue:** Administer prescribed analgesics and corticosteroids. Schedule rest periods between activities. Apply *cold* therapy to inflamed joints, not heat. - **Nutrition:** Provide a balanced diet. If on high-dose steroids, monitor blood glucose and restrict sodium to manage fluid retention. Infection control is the priority because preventing sepsis outweighs managing non-life-threatening symptoms during the critical immunosuppressive treatment window. ## 핵심 개념 - **Systemic Lupus Erythematosus** — Systemic lupus erythematosus. A chronic autoimmune disease that attacks multiple organs and systems in the body. The immune system produces autoantibodies that cause inflammation and damage to healthy tissues. - **Anti-dsDNA antibodies** — Antibody against double-stranded DNA. One of the specific markers for SLE, closely associated with disease activity and especially renal involvement (lupus nephritis). Rising levels suggest worsening of the disease. - **Complement levels (C3, C4)** — Levels of complement proteins C3 and C4. These are involved in immune response and defense against infection. During SLE exacerbation, they are consumed due to immune complex formation, leading to decreased levels. A decrease indicates disease activity and impaired immune function. - **Lupus flare** — Lupus flare-up. This is a period when disease activity suddenly increases, causing symptoms (joint pain, rash, fatigue, fever, etc.) to worsen and lab values to deteriorate. During this time, focus should be on intensifying treatment and preventing complications. - **Infection Control Precautions** — Infection control preventive measures. A set of measures to protect immunocompromised patients, including strict hand hygiene, implementation of contact precautions when necessary, limiting contact with infected individuals, checking vaccination status, and monitoring for early signs of infection. ## 같은 주제 문제 - [A 52-year-old female client with systemic lupus erythematosus (SLE) is admitted to the med…](https://mymerci.kr/pages/nclex_q.php?qn_id=540847) - [A nurse is assessing a 45-year-old female client who has been experiencing joint pain, fat…](https://mymerci.kr/pages/nclex_q.php?qn_id=540848) - [A nurse is assessing a 45-year-old female client with suspected systemic lupus erythematos…](https://mymerci.kr/pages/nclex_q.php?qn_id=540849) - [A nurse is caring for a client with systemic lupus erythematosus (SLE) who is experiencing…](https://mymerci.kr/pages/nclex_q.php?qn_id=540850) - [A nurse is caring for a client with systemic lupus erythematosus (SLE) who is experiencing…](https://mymerci.kr/pages/nclex_q.php?qn_id=540852) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._