NR 464 - EXAM 3 (SAUNDERS) 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." - 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
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 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
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.
4. The client probably has another infection that is developing. - Answer -2. The client
has disseminated histoplasmosis infection.
Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory
infection in the client with AIDS and then becomes a disseminated infection, with
enlargement of lymph nodes, spleen, and liver. The client experiences dyspnea, fever,
cough, and weight loss. The remaining options are incorrect.
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is
experiencing night fever and night sweats. Which nursing interventions would be helpful
in managing this symptom? Select all that apply.
1. Keep liquids at the bedside.
2. Place a towel over the pillowcase.
3. Make sure the pillow has a plastic cover.
4. Keep a change of bed linens nearby in case they are needed.
5. Administer an antipyretic after the client has a spike in temperature. - Answer -1.
Keep liquids at the bedside.
2. Place a towel over the pillowcase.
3. Make sure the pillow has a plastic cover.
4. Keep a change of bed linens nearby in case they are needed.
For clients with AIDS who experience night fever and night sweats, the nurse may offer
the client an antipyretic of choice before the client goes to sleep rather than waiting until
the client spikes a temperature. Keeping a change of bed linens and night clothes
nearby for use also is helpful. The pillow should have a plastic cover, and a towel may
be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at
the bedside to drink.
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
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 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
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.
4. The client probably has another infection that is developing. - Answer -2. The client
has disseminated histoplasmosis infection.
Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory
infection in the client with AIDS and then becomes a disseminated infection, with
enlargement of lymph nodes, spleen, and liver. The client experiences dyspnea, fever,
cough, and weight loss. The remaining options are incorrect.
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is
experiencing night fever and night sweats. Which nursing interventions would be helpful
in managing this symptom? Select all that apply.
1. Keep liquids at the bedside.
2. Place a towel over the pillowcase.
3. Make sure the pillow has a plastic cover.
4. Keep a change of bed linens nearby in case they are needed.
5. Administer an antipyretic after the client has a spike in temperature. - Answer -1.
Keep liquids at the bedside.
2. Place a towel over the pillowcase.
3. Make sure the pillow has a plastic cover.
4. Keep a change of bed linens nearby in case they are needed.
For clients with AIDS who experience night fever and night sweats, the nurse may offer
the client an antipyretic of choice before the client goes to sleep rather than waiting until
the client spikes a temperature. Keeping a change of bed linens and night clothes
nearby for use also is helpful. The pillow should have a plastic cover, and a towel may
be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at
the bedside to drink.
