NR 464 - Exam 3 (Saunders) Test Questions with Verified Answers
1. The nurse provides home care instructions to a client 1. "I should take hot baths
with systemic lupus erythematosus and tells the client because they are relax-
about methods to manage fatigue. Which statement ing."
by the client indicates a need for further instruction?
To help reduce fatigue in
1. "I should take hot baths because they are relaxing." the client with systemic
lupus erythematosus, the
2. "I should sit whenever possible to conserve my en- nurse should instruct the
ergy." client to sit whenever pos-
sible, avoid hot baths (be-
3. "I should avoid long periods of rest because it causes
cause they exacerbate fa-
joint stiffness."
tigue), schedule moderate
low-impact exercises when
4. "I should do some exercises, such as walking, when
not fatigued, and maintain
I am not fatigued."
a balanced diet. The client
is instructed to avoid long
periods of rest because it
promotes joint stittness.
2. The nurse is assisting in planning care for a client with 1. Protecting the client
a diagnosis of immunodeficiency and should incorpo- from infection
rate 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 func-
tion
3.
,NR 464 - Exam 3 (Saunders) Test Questions with Verified Answers
The client with acquired immunodeficiency syndrome 3. Positive punch biopsy of
is diagnosed with cutaneous Kaposi's sarcoma. Based the cutaneous lesions
on this diagnosis, the nurse understands that this has
been confirmed by which finding? Kaposi's sarcoma lesions
begin as red, dark blue,
1. Swelling in the genital area or purple macules on the
lower legs that change
2. Swelling in the lower extremities into plaques. These large
plaques ulcerate or open
3. Positive punch biopsy of the cutaneous lesions and drain. The lesions
spread by metastasis
4. Appearance of reddish-blue lesions noted on the
through the upper body
skin
and then to the face and
oral mucosa. They can
move to the lymphatic sys-
tem, lungs, and gastroin-
testinal tract. Late disease
results in swelling and
pain in the lower extrem-
ities, penis, scrotum, or
face. Diagnosis is made
by punch biopsy of cuta-
neous lesions and biop-
sy of pulmonary and gas-
trointestinal lesions.
4. The home care nurse is preparing to visit a client who 3. Fever, hypertension, and
has undergone renal transplantation. The nurse devel- graft tenderness
ops 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?
,NR 464 - Exam 3 (Saunders) Test Questions with Verified Answers
1. Fever, hypotension, and polyuria
2. Hypertension, polyuria, and thirst
3. Fever, hypertension, and graft tenderness
4. Hypotension, graft tenderness, and hypothermia
5. A client with acquired immunodeficiency syndrome 3. Complete blood cell
(AIDS) has been started on therapy with zidovudine. (CBC) count
The nurse should monitor the results of which labora-
tory blood study for adverse effects of therapy? Acquired immunodefi-
ciency syndrome is a vi-
1. Creatinine level ral disease caused by the
human immunodeficiency
2. Potassium concentration virus (HIV), which destroys
T cells, thereby increasing
3. Complete blood cell (CBC) count susceptibility to infection
and malignancy. Common
4. Blood urea nitrogen (BUN) level
adverse ettects of zidovu-
dine are agranulocytope-
nia and anemia. The nurse
should monitor the CBC
count for these changes.
Creatinine, potassium, and
BUN are unrelated to this
medication.
6. The nurse is performing an assessment on a female 3. Facial rash
client who complains of fatigue, weakness, muscle and
joint pain, anorexia, and photosensitivity. Systemic lu- Systemic lupus erythe-
pus erythematosus (SLE) is suspected. What should matosus is a chronic,
, NR 464 - Exam 3 (Saunders) Test Questions with Verified Answers
the nurse further assess for that also is indicative of progressive, inflammatory
SLE? connective tissue disorder
that can cause major body
1. Ascites organs and systems to fail.
A butterfly rash on the
2. Emboli cheeks and bridge of the
nose is an essential sign
3. Facial rash
of SLE. Ascites and emboli
4. Two hemoglobin S genes are found in many condi-
tions but are not associ-
ated with SLE. Two hemo-
globin S genes are found
in sickle cell anemia.
7. A client has requested and undergone testing for hu- 2. A Western blot will
man immunodeficiency virus (HIV) infection. The client be done to confirm these
asks what will be done next because the result of the findings.
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 find-
ings.
3. The client probably will have a bone marrow biopsy
done.
4. A CD4+ cell count will be done to measure T helper
lymphocytes.
8.
1. The nurse provides home care instructions to a client 1. "I should take hot baths
with systemic lupus erythematosus and tells the client because they are relax-
about methods to manage fatigue. Which statement ing."
by the client indicates a need for further instruction?
To help reduce fatigue in
1. "I should take hot baths because they are relaxing." the client with systemic
lupus erythematosus, the
2. "I should sit whenever possible to conserve my en- nurse should instruct the
ergy." client to sit whenever pos-
sible, avoid hot baths (be-
3. "I should avoid long periods of rest because it causes
cause they exacerbate fa-
joint stiffness."
tigue), schedule moderate
low-impact exercises when
4. "I should do some exercises, such as walking, when
not fatigued, and maintain
I am not fatigued."
a balanced diet. The client
is instructed to avoid long
periods of rest because it
promotes joint stittness.
2. The nurse is assisting in planning care for a client with 1. Protecting the client
a diagnosis of immunodeficiency and should incorpo- from infection
rate 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 func-
tion
3.
,NR 464 - Exam 3 (Saunders) Test Questions with Verified Answers
The client with acquired immunodeficiency syndrome 3. Positive punch biopsy of
is diagnosed with cutaneous Kaposi's sarcoma. Based the cutaneous lesions
on this diagnosis, the nurse understands that this has
been confirmed by which finding? Kaposi's sarcoma lesions
begin as red, dark blue,
1. Swelling in the genital area or purple macules on the
lower legs that change
2. Swelling in the lower extremities into plaques. These large
plaques ulcerate or open
3. Positive punch biopsy of the cutaneous lesions and drain. The lesions
spread by metastasis
4. Appearance of reddish-blue lesions noted on the
through the upper body
skin
and then to the face and
oral mucosa. They can
move to the lymphatic sys-
tem, lungs, and gastroin-
testinal tract. Late disease
results in swelling and
pain in the lower extrem-
ities, penis, scrotum, or
face. Diagnosis is made
by punch biopsy of cuta-
neous lesions and biop-
sy of pulmonary and gas-
trointestinal lesions.
4. The home care nurse is preparing to visit a client who 3. Fever, hypertension, and
has undergone renal transplantation. The nurse devel- graft tenderness
ops 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?
,NR 464 - Exam 3 (Saunders) Test Questions with Verified Answers
1. Fever, hypotension, and polyuria
2. Hypertension, polyuria, and thirst
3. Fever, hypertension, and graft tenderness
4. Hypotension, graft tenderness, and hypothermia
5. A client with acquired immunodeficiency syndrome 3. Complete blood cell
(AIDS) has been started on therapy with zidovudine. (CBC) count
The nurse should monitor the results of which labora-
tory blood study for adverse effects of therapy? Acquired immunodefi-
ciency syndrome is a vi-
1. Creatinine level ral disease caused by the
human immunodeficiency
2. Potassium concentration virus (HIV), which destroys
T cells, thereby increasing
3. Complete blood cell (CBC) count susceptibility to infection
and malignancy. Common
4. Blood urea nitrogen (BUN) level
adverse ettects of zidovu-
dine are agranulocytope-
nia and anemia. The nurse
should monitor the CBC
count for these changes.
Creatinine, potassium, and
BUN are unrelated to this
medication.
6. The nurse is performing an assessment on a female 3. Facial rash
client who complains of fatigue, weakness, muscle and
joint pain, anorexia, and photosensitivity. Systemic lu- Systemic lupus erythe-
pus erythematosus (SLE) is suspected. What should matosus is a chronic,
, NR 464 - Exam 3 (Saunders) Test Questions with Verified Answers
the nurse further assess for that also is indicative of progressive, inflammatory
SLE? connective tissue disorder
that can cause major body
1. Ascites organs and systems to fail.
A butterfly rash on the
2. Emboli cheeks and bridge of the
nose is an essential sign
3. Facial rash
of SLE. Ascites and emboli
4. Two hemoglobin S genes are found in many condi-
tions but are not associ-
ated with SLE. Two hemo-
globin S genes are found
in sickle cell anemia.
7. A client has requested and undergone testing for hu- 2. A Western blot will
man immunodeficiency virus (HIV) infection. The client be done to confirm these
asks what will be done next because the result of the findings.
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 find-
ings.
3. The client probably will have a bone marrow biopsy
done.
4. A CD4+ cell count will be done to measure T helper
lymphocytes.
8.
