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: 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 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 - ANSWER: 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. - ANSWER: 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
3. Dyspnea at rest
4. Dyspnea on exertion - ANSWER: 2. Cough
Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The
client with P. jiroveci infection usually has a cough as the first sign. The cough begins as nonproductive and
then progresses to productive. Later signs and symptoms include fever, dyspnea on exertion, and finally
dyspnea at rest.
A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis.
During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse
interpret this assessment finding?
1. The histoplasmosis is resolving.
2. The client has disseminated histoplasmosis infection.
3. This is a side effect of the medications given to treat AIDS.
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 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 - ANSWER: 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. - ANSWER: 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
3. Dyspnea at rest
4. Dyspnea on exertion - ANSWER: 2. Cough
Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The
client with P. jiroveci infection usually has a cough as the first sign. The cough begins as nonproductive and
then progresses to productive. Later signs and symptoms include fever, dyspnea on exertion, and finally
dyspnea at rest.
A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis.
During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse
interpret this assessment finding?
1. The histoplasmosis is resolving.
2. The client has disseminated histoplasmosis infection.
3. This is a side effect of the medications given to treat AIDS.
