NR 464 - Exam 3 (Saunders) QUESTIONS AND
ANSWERS | LATEST VERSION
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Terms in this set (92)
The nurse provides home care 1. "I should take hot baths because they are
instructions to a client with systemic relaxing."
lupus erythematosus and tells the
client about methods to manage To help reduce fatigue in the client with systemic
fatigue. Which statement by the client lupus erythematosus, the nurse should instruct the
indicates a need for further client to sit whenever possible, avoid hot baths
instruction? (because they exacerbate fatigue), schedule
moderate low-impact exercises when not fatigued,
1. "I should take hot baths because and maintain a balanced diet. The client is
they are relaxing." instructed to avoid long periods of rest because it
promotes joint stiffness.
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."
,The nurse is assisting in planning care 1. Protecting the client from infection
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
The client with acquired 3. Positive punch biopsy of the cutaneous lesions
immunodeficiency syndrome is
diagnosed with cutaneous Kaposi's Kaposi's sarcoma lesions begin as red, dark blue, or
sarcoma. Based on this diagnosis, the purple macules on the lower legs that change into
nurse understands that this has been plaques. These large plaques ulcerate or open and
confirmed by which finding? drain. The lesions spread by metastasis through the
upper body and then to the face and oral mucosa.
1. Swelling in the genital area They can move to the lymphatic system, lungs, and
gastrointestinal tract. Late disease results in swelling
2. Swelling in the lower extremities and pain in the lower extremities, penis, scrotum, or
face. Diagnosis is made by punch biopsy of
3. Positive punch biopsy of the cutaneous lesions and biopsy of pulmonary and
cutaneous lesions gastrointestinal lesions.
4. Appearance of reddish-blue
lesions noted on the skin
,The home care nurse is preparing to 3. Fever, hypertension, and graft tenderness
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
A client with acquired 3. Complete blood cell (CBC) count
immunodeficiency syndrome (AIDS)
has been started on therapy with Acquired immunodeficiency syndrome is a viral
zidovudine. The nurse should monitor disease caused by the human immunodeficiency
the results of which laboratory blood virus (HIV), which destroys T cells, thereby
study for adverse effects of therapy? increasing susceptibility to infection and
malignancy. Common adverse effects of
1. Creatinine level zidovudine are agranulocytopenia and anemia. The
nurse should monitor the CBC count for these
2. Potassium concentration changes. Creatinine, potassium, and BUN are
unrelated to this medication.
3. Complete blood cell (CBC) count
4. Blood urea nitrogen (BUN) level
, The nurse is performing an 3. Facial rash
assessment on a female client who
complains of fatigue, weakness, Systemic lupus erythematosus is a chronic,
muscle and joint pain, anorexia, and progressive, inflammatory connective tissue
photosensitivity. Systemic lupus disorder that can cause major body organs and
erythematosus (SLE) is suspected. systems to fail. A butterfly rash on the cheeks and
What should the nurse further assess bridge of the nose is an essential sign of SLE.
for that also is indicative of SLE? Ascites and emboli are found in many conditions
but are not associated with SLE. Two hemoglobin S
1. Ascites genes are found in sickle cell anemia.
2. Emboli
3. Facial rash
4. Two hemoglobin S genes
ANSWERS | LATEST VERSION
Save
Terms in this set (92)
The nurse provides home care 1. "I should take hot baths because they are
instructions to a client with systemic relaxing."
lupus erythematosus and tells the
client about methods to manage To help reduce fatigue in the client with systemic
fatigue. Which statement by the client lupus erythematosus, the nurse should instruct the
indicates a need for further client to sit whenever possible, avoid hot baths
instruction? (because they exacerbate fatigue), schedule
moderate low-impact exercises when not fatigued,
1. "I should take hot baths because and maintain a balanced diet. The client is
they are relaxing." instructed to avoid long periods of rest because it
promotes joint stiffness.
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."
,The nurse is assisting in planning care 1. Protecting the client from infection
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
The client with acquired 3. Positive punch biopsy of the cutaneous lesions
immunodeficiency syndrome is
diagnosed with cutaneous Kaposi's Kaposi's sarcoma lesions begin as red, dark blue, or
sarcoma. Based on this diagnosis, the purple macules on the lower legs that change into
nurse understands that this has been plaques. These large plaques ulcerate or open and
confirmed by which finding? drain. The lesions spread by metastasis through the
upper body and then to the face and oral mucosa.
1. Swelling in the genital area They can move to the lymphatic system, lungs, and
gastrointestinal tract. Late disease results in swelling
2. Swelling in the lower extremities and pain in the lower extremities, penis, scrotum, or
face. Diagnosis is made by punch biopsy of
3. Positive punch biopsy of the cutaneous lesions and biopsy of pulmonary and
cutaneous lesions gastrointestinal lesions.
4. Appearance of reddish-blue
lesions noted on the skin
,The home care nurse is preparing to 3. Fever, hypertension, and graft tenderness
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
A client with acquired 3. Complete blood cell (CBC) count
immunodeficiency syndrome (AIDS)
has been started on therapy with Acquired immunodeficiency syndrome is a viral
zidovudine. The nurse should monitor disease caused by the human immunodeficiency
the results of which laboratory blood virus (HIV), which destroys T cells, thereby
study for adverse effects of therapy? increasing susceptibility to infection and
malignancy. Common adverse effects of
1. Creatinine level zidovudine are agranulocytopenia and anemia. The
nurse should monitor the CBC count for these
2. Potassium concentration changes. Creatinine, potassium, and BUN are
unrelated to this medication.
3. Complete blood cell (CBC) count
4. Blood urea nitrogen (BUN) level
, The nurse is performing an 3. Facial rash
assessment on a female client who
complains of fatigue, weakness, Systemic lupus erythematosus is a chronic,
muscle and joint pain, anorexia, and progressive, inflammatory connective tissue
photosensitivity. Systemic lupus disorder that can cause major body organs and
erythematosus (SLE) is suspected. systems to fail. A butterfly rash on the cheeks and
What should the nurse further assess bridge of the nose is an essential sign of SLE.
for that also is indicative of SLE? Ascites and emboli are found in many conditions
but are not associated with SLE. Two hemoglobin S
1. Ascites genes are found in sickle cell anemia.
2. Emboli
3. Facial rash
4. Two hemoglobin S genes
