NR 464 - Exam 3 (Saunders)
A test for the presence of rheumatoid factor is performed in a client with a diagnosis of
rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this
disease?
1. Neutropenia
2. Hyperglycemia
3. Antigens of immunoglobulin A (IgA)
4. Unusual antibodies of the IgG and IgM type - ✔️✔️4. Unusual antibodies of the IgG
and IgM type
Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune
disease process that affects primarily the synovial joints. The test for rheumatoid factor
detects the presence of unusual antibodies of the IgG and IgM type, which develop in a
number of connective tissue diseases. The other options are incorrect.
A complete blood cell count is performed on a client with systemic lupus erythematosus
(SLE). The nurse suspects that which finding will be reported with this blood test?
1. Increased neutrophils
2. Increased red blood cell count
3. Increased white blood cell count
4. Decreased numbers of all cell types - ✔️✔️4. Decreased numbers of all cell types
In the client with SLE, a complete blood cell count commonly shows pancytopenia, a
decrease in all cell types. This probably is caused by a direct attack on all blood cells or
bone marrow by immune complexes. The other options are incorrect.
The nurse is reviewing the health care record of a client with a new diagnosis of
rheumatoid arthritis (RA). The nurse should recognize that which are early clinical
manifestations of this disorder? Select all that apply.
1. Fatigue
2. Anorexia
,3. High fever
4. Weight loss
5. Generalized weakness - ✔️✔️1. Fatigue
2. Anorexia
5. Generalized weakness
Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade
fever, paresthesias. Weight loss is one of the late manifestations.
The client with acquired immunodeficiency syndrome is diagnosed with cutaneous
Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been
confirmed by which finding?
1. Swelling in the genital area
2. Swelling in the lower extremities
3. Positive punch biopsy of the cutaneous lesions
4. Appearance of reddish-blue lesions noted on the skin - ✔️✔️3. Positive punch
biopsy of the cutaneous lesions
Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs
that change into plaques. These large plaques ulcerate or open and drain. The lesions
spread by metastasis through the upper body and then to the face and oral mucosa.
They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease
results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis
is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and
gastrointestinal lesions.
The home care nurse is preparing to visit a client who has undergone renal
transplantation. The nurse develops a plan of care that includes monitoring the client for
signs of acute graft rejection. The nurse documents in the plan to assess the client for
which signs of acute graft rejection?
1. Fever, hypotension, and polyuria
2. Hypertension, polyuria, and thirst
3. Fever, hypertension, and graft tenderness
,4. Hypotension, graft tenderness, and hypothermia - ✔️✔️3. Fever, hypertension, and
graft tenderness
A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy
with zidovudine. The nurse should monitor the results of which laboratory blood study
for adverse effects of therapy?
1. Creatinine level
2. Potassium concentration
3. Complete blood cell (CBC) count
4. Blood urea nitrogen (BUN) level - ✔️✔️3. Complete blood cell (CBC) count
Acquired immunodeficiency syndrome is a viral disease caused by the human
immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility
to infection and malignancy. Common adverse effects of zidovudine are
agranulocytopenia and anemia. The nurse should monitor the CBC count for these
changes. Creatinine, potassium, and BUN are unrelated to this medication.
The nurse provides home care instructions to a client with systemic lupus
erythematosus and tells the client about methods to manage fatigue. Which statement
by the client indicates a need for further instruction?
1. "I should take hot baths because they are relaxing."
2. "I should sit whenever possible to conserve my energy."
3. "I should avoid long periods of rest because it causes joint stiffness."
4. "I should do some exercises, such as walking, when I am not fatigued." - ✔️✔️1. "I
should take hot baths because they are relaxing."
To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should
instruct the client to sit whenever possible, avoid hot baths (because they exacerbate
fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a
balanced diet. The client is instructed to avoid long periods of rest because it promotes
joint stiffness.
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency
and should incorporate which action as a priority in the plan?
1. Protecting the client from infection
, 2. Providing emotional support to decrease fear
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function - ✔️✔️1. Protecting the client
from infection
The nurse is performing an assessment on a female client who complains of fatigue,
weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus
erythematosus (SLE) is suspected. What should the nurse further assess for that also is
indicative of SLE?
1. Ascites
2. Emboli
3. Facial rash
4. Two hemoglobin S genes - ✔️✔️3. Facial rash
Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue
disorder that can cause major body organs and systems to fail. A butterfly rash on the
cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboli are found
in many conditions but are not associated with SLE. Two hemoglobin S genes are found
in sickle cell anemia.
A client has requested and undergone testing for human immunodeficiency virus (HIV)
infection. The client asks what will be done next because the result of the enzyme-
linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should
the nurse be aware of before responding to the client?
1. No further diagnostic studies are needed.
2. A Western blot will be done to confirm these findings.
3. The client probably will have a bone marrow biopsy done.
4. A CD4+ cell count will be done to measure T helper lymphocytes. - ✔️✔️2. A
Western blot will be done to confirm these findings.
The nurse is caring for a client with acquired immunodeficiency syndrome and detects
early infection with Pneumocystis jiroveci by monitoring the client for which clinical
manifestation?
1. Fever
A test for the presence of rheumatoid factor is performed in a client with a diagnosis of
rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this
disease?
1. Neutropenia
2. Hyperglycemia
3. Antigens of immunoglobulin A (IgA)
4. Unusual antibodies of the IgG and IgM type - ✔️✔️4. Unusual antibodies of the IgG
and IgM type
Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune
disease process that affects primarily the synovial joints. The test for rheumatoid factor
detects the presence of unusual antibodies of the IgG and IgM type, which develop in a
number of connective tissue diseases. The other options are incorrect.
A complete blood cell count is performed on a client with systemic lupus erythematosus
(SLE). The nurse suspects that which finding will be reported with this blood test?
1. Increased neutrophils
2. Increased red blood cell count
3. Increased white blood cell count
4. Decreased numbers of all cell types - ✔️✔️4. Decreased numbers of all cell types
In the client with SLE, a complete blood cell count commonly shows pancytopenia, a
decrease in all cell types. This probably is caused by a direct attack on all blood cells or
bone marrow by immune complexes. The other options are incorrect.
The nurse is reviewing the health care record of a client with a new diagnosis of
rheumatoid arthritis (RA). The nurse should recognize that which are early clinical
manifestations of this disorder? Select all that apply.
1. Fatigue
2. Anorexia
,3. High fever
4. Weight loss
5. Generalized weakness - ✔️✔️1. Fatigue
2. Anorexia
5. Generalized weakness
Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade
fever, paresthesias. Weight loss is one of the late manifestations.
The client with acquired immunodeficiency syndrome is diagnosed with cutaneous
Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been
confirmed by which finding?
1. Swelling in the genital area
2. Swelling in the lower extremities
3. Positive punch biopsy of the cutaneous lesions
4. Appearance of reddish-blue lesions noted on the skin - ✔️✔️3. Positive punch
biopsy of the cutaneous lesions
Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs
that change into plaques. These large plaques ulcerate or open and drain. The lesions
spread by metastasis through the upper body and then to the face and oral mucosa.
They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease
results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis
is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and
gastrointestinal lesions.
The home care nurse is preparing to visit a client who has undergone renal
transplantation. The nurse develops a plan of care that includes monitoring the client for
signs of acute graft rejection. The nurse documents in the plan to assess the client for
which signs of acute graft rejection?
1. Fever, hypotension, and polyuria
2. Hypertension, polyuria, and thirst
3. Fever, hypertension, and graft tenderness
,4. Hypotension, graft tenderness, and hypothermia - ✔️✔️3. Fever, hypertension, and
graft tenderness
A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy
with zidovudine. The nurse should monitor the results of which laboratory blood study
for adverse effects of therapy?
1. Creatinine level
2. Potassium concentration
3. Complete blood cell (CBC) count
4. Blood urea nitrogen (BUN) level - ✔️✔️3. Complete blood cell (CBC) count
Acquired immunodeficiency syndrome is a viral disease caused by the human
immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility
to infection and malignancy. Common adverse effects of zidovudine are
agranulocytopenia and anemia. The nurse should monitor the CBC count for these
changes. Creatinine, potassium, and BUN are unrelated to this medication.
The nurse provides home care instructions to a client with systemic lupus
erythematosus and tells the client about methods to manage fatigue. Which statement
by the client indicates a need for further instruction?
1. "I should take hot baths because they are relaxing."
2. "I should sit whenever possible to conserve my energy."
3. "I should avoid long periods of rest because it causes joint stiffness."
4. "I should do some exercises, such as walking, when I am not fatigued." - ✔️✔️1. "I
should take hot baths because they are relaxing."
To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should
instruct the client to sit whenever possible, avoid hot baths (because they exacerbate
fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a
balanced diet. The client is instructed to avoid long periods of rest because it promotes
joint stiffness.
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency
and should incorporate which action as a priority in the plan?
1. Protecting the client from infection
, 2. Providing emotional support to decrease fear
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function - ✔️✔️1. Protecting the client
from infection
The nurse is performing an assessment on a female client who complains of fatigue,
weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus
erythematosus (SLE) is suspected. What should the nurse further assess for that also is
indicative of SLE?
1. Ascites
2. Emboli
3. Facial rash
4. Two hemoglobin S genes - ✔️✔️3. Facial rash
Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue
disorder that can cause major body organs and systems to fail. A butterfly rash on the
cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboli are found
in many conditions but are not associated with SLE. Two hemoglobin S genes are found
in sickle cell anemia.
A client has requested and undergone testing for human immunodeficiency virus (HIV)
infection. The client asks what will be done next because the result of the enzyme-
linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should
the nurse be aware of before responding to the client?
1. No further diagnostic studies are needed.
2. A Western blot will be done to confirm these findings.
3. The client probably will have a bone marrow biopsy done.
4. A CD4+ cell count will be done to measure T helper lymphocytes. - ✔️✔️2. A
Western blot will be done to confirm these findings.
The nurse is caring for a client with acquired immunodeficiency syndrome and detects
early infection with Pneumocystis jiroveci by monitoring the client for which clinical
manifestation?
1. Fever
