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."
Answer: "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: 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
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
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
Answer: 3. Facial rash
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.
Answer: 2. A Western blot will be done to confirm these
findings.
(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."
Answer: "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: 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
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
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
Answer: 3. Facial rash
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.
Answer: 2. A Western blot will be done to confirm these
findings.
