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NR 464 ACTUAL EXAM 3 | WITH COMPLETE QUESTIONS AND
ANSWERS | 2025/206 LATEST UPDATED | 100 % RATED AND VERIFIED
SOLUTIONS | GET AN A+
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
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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?
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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?
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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
NR 464 ACTUAL EXAM 3 | WITH COMPLETE QUESTIONS AND
ANSWERS | 2025/206 LATEST UPDATED | 100 % RATED AND VERIFIED
SOLUTIONS | GET AN A+
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
,2|Page
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?
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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?
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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
