NR 464 - Exam 3 (Saunders)
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 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 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
2. Cough
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 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 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
2. Cough
