NR 464 EXAM REVISION QUESTIONS WITH
100% VERIFIED ANSWERS!!
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 immunodeficiency has inadequate or an absence of immune bodies and is at risk
for infection. The priority nursing intervention would be to protect the client from infection.
Options 2, 3, and 4 may be components of care but are not the priority.
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
100% VERIFIED ANSWERS!!
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 immunodeficiency has inadequate or an absence of immune bodies and is at risk
for infection. The priority nursing intervention would be to protect the client from infection.
Options 2, 3, and 4 may be components of care but are not the priority.
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
