NR 464 - Exam 3 (Saunders) With
complete verified solutions (Guaranteed
Pass)
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." - answer 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 - answer 1.
Protecting the client from infection
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 - answer 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 - answer 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 - answer 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
complete verified solutions (Guaranteed
Pass)
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." - answer 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 - answer 1.
Protecting the client from infection
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 - answer 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 - answer 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 - answer 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
