# Situation: A 26-year-old woman with systemic lupus erythematosus (SLE) comes to the medical outpatient clinic for follow-up. She takes hydroxychloroquine daily and prednisone 5 mg daily. Her usual blood pressure is 110/70 mmHg. At this visit she reports four new findings. Which finding should the nurse report as the MOST serious?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629826  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 26-year-old woman with systemic lupus erythematosus (SLE) comes to the medical outpatient clinic for follow-up. She takes hydroxychloroquine daily and prednisone 5 mg daily. Her usual blood pressure is 110/70 mmHg.

At this visit she reports four new findings. Which finding should the nurse report as the MOST serious?

## 보기

1. Hair thinning she has noticed when combing over the past month
2. Aching and stiffness in both wrists for an hour each morning
3. Foamy urine, puffy ankles, and a blood pressure of 150/96 mmHg **✔ 정답**
4. A red rash across both cheeks after a long day in the sun

**정답: 3**

## 해설

Foamy urine (proteinuria), edema, and a new rise in blood pressure from her baseline of 110/70 mmHg suggest lupus nephritis, the most common serious organ involvement in SLE. It can progress to kidney failure and needs prompt evaluation of urine protein and creatinine. The other findings are also signs of disease activity but do not threaten a major organ.

## 심화 해설

Organ threat ranks highest
Systemic lupus erythematosus (SLE) can affect almost any tissue, but the findings are not equally serious. When a client reports several new problems, the nurse ranks them by threat to a major organ. Foamy urine suggests proteinuria, puffy ankles show edema, and a blood pressure of 150/96 mmHg against her usual 110/70 mmHg is new hypertension. Together these findings suggest lupus nephritis, the most common serious organ involvement in SLE, which can progress to kidney failure. This is the finding to report as the most serious.

Why kidney involvement is so important
In lupus nephritis, immune complexes deposit in the glomeruli and cause inflammation. Damaged glomeruli leak protein into the urine, the loss of protein and retention of sodium cause edema, and impaired kidney function raises blood pressure. Early disease may cause few symptoms, so new edema, frothy urine, or a rise in blood pressure must be evaluated promptly with urinalysis for protein and blood, urine protein measurement, and serum creatinine. Early treatment can preserve kidney function.

| Finding | Meaning | Organ threat? |
| --- | --- | --- |
| Foamy urine, ankle edema, BP 150/96 | Suggests lupus nephritis | Yes: kidney |
| Hair thinning | Disease activity | No |
| Morning stiffness of both wrists | Arthralgia or arthritis of SLE | No |
| Malar rash after sun exposure | Skin activity, photosensitivity | No |

Why the other findings rank lower
Hair thinning, morning joint stiffness, and a malar rash after sun exposure are all signs that the disease is active, and they deserve attention, but none threatens a vital organ. Joint involvement in SLE is common and usually non-erosive. The rash calls for sun protection and review of treatment. These findings are recorded and reported in the course of follow-up, but the kidney findings are reported first.

Watch out! In SLE and other systemic diseases, a new rise in blood pressure from a low baseline is easy to overlook. Compare every reading with the client's usual value; 150/96 mmHg is a large change for someone who usually runs 110/70 mmHg.

Exam takeaway
Key point! When ranking SLE findings, kidney, central nervous system, heart, and lung involvement come before skin, hair, and joint symptoms. Foamy urine, edema, and new hypertension point to lupus nephritis and need prompt evaluation of urine protein and creatinine.

## 임상 시나리오

Lupus Nephritis Warning SignsRanking new findings in SLE
Foamy urine (proteinuria), ankle edema, and a new blood pressure of 150/96 mmHg from a baseline of 110/70 suggest lupus nephritis.

Lupus nephritis is the most common serious organ involvement in SLE and can progress to kidney failure. It needs prompt urine protein and creatinine testing.

Hair thinning, joint stiffness, and a malar rash show disease activity but do not threaten a major organ, so they rank lower.

CautionAlways compare blood pressure with the client's own baseline; a modest number can be a large rise for her.

## 핵심 개념

- **Systemic lupus erythematosus** — A chronic autoimmune disease in which immune complexes cause inflammation in the skin, joints, kidneys, and other organs.
- **Lupus nephritis** — Kidney inflammation from SLE causing proteinuria, edema, hypertension, and possible kidney failure.
- **Proteinuria** — Abnormal protein in the urine, often seen as foamy urine, indicating glomerular damage.
- **Malar rash** — A red rash across the cheeks and nose in SLE, often triggered by sun exposure.

## 같은 주제 문제

- [Situation: A 29-year-old woman has a pre-employment medical examination at a private manuf…](https://mymerci.kr/pages/nclex_q.php?qn_id=629716)
- [Situation: A 29-year-old woman has a pre-employment medical examination at a private manuf…](https://mymerci.kr/pages/nclex_q.php?qn_id=629717)
- [Situation: A 29-year-old woman has a pre-employment medical examination at a private manuf…](https://mymerci.kr/pages/nclex_q.php?qn_id=629718)
- [Situation: A 29-year-old woman has a pre-employment medical examination at a private manuf…](https://mymerci.kr/pages/nclex_q.php?qn_id=629719)
- [Situation: A 34-year-old man was diagnosed with human immunodeficiency virus (HIV) infecti…](https://mymerci.kr/pages/nclex_q.php?qn_id=629720)
- [Situation: A 34-year-old man was diagnosed with human immunodeficiency virus (HIV) infecti…](https://mymerci.kr/pages/nclex_q.php?qn_id=629721)
- [Situation: A 34-year-old man was diagnosed with human immunodeficiency virus (HIV) infecti…](https://mymerci.kr/pages/nclex_q.php?qn_id=629722)
- [Situation: A 41-year-old man is admitted to the medical ward with weakness that began in b…](https://mymerci.kr/pages/nclex_q.php?qn_id=629723)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._