NR 464 – Exam 3 (Saunders) | Complex Adult Health Nursing |
Chamberlain University | 2025 | Exam Review and Saunders Practice
Questions
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." - correct 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 - correct 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 - correct 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 - correct 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 - correct 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 - correct 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. - correct 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
Chamberlain University | 2025 | Exam Review and Saunders Practice
Questions
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." - correct 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 - correct 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 - correct 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 - correct 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 - correct 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 - correct 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. - correct 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
