NR 464 Exam Latest 2023 - 2024

NR 464 Exam (Latest 2023 - 2024) New Full Questions and Answers ( Included ) 100% Correct

• The nurse provides home care instructions to a client with systemic lupuserythematosus and tells the

client about methods to manage fatigue. Which statement by the client indicates a need for further instruction?

• "I should take hot baths because they are relaxing."
• "I should sit whenever possible to conserve my energy."
• "I should avoid long periods of rest because it causes joint stiffness."

• "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 restbecause 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 theplan?

• Protecting the client from infection
• Providing emotional support to decrease fear
• Encouraging discussion about lifestyle changes
• Identifying factors that decreased the immune function: 1. Protecting theclient from infection

• The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma.

Based on this diagnosis, the nurse understandsthat this has been confirmed by which finding?

• Swelling in the genital area
• Swelling in the lower extremities
• Positive punch biopsy of the cutaneous lesions 1 / 4

• Appearance of reddish-blue lesions noted on the skin: 3. Positive punchbiopsy 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. Thelesions spread by metastasis through the upper body and then to the face and oralmucosa. 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 renaltransplantation. 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?

• Fever, hypotension, and polyuria

• Hypertension, polyuria, and thirst

• Fever, hypertension, and graft tenderness

• Hypotension, graft tenderness, and hypothermia: 3. Fever, hypertension, andgraft tenderness

• A client with acquired immunodeficiency syndrome (AIDS) has been startedon therapy with

zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy?

• Creatinine level
• Potassium concentration
• 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 areagranulocytopenia and anemia. The nurse should monitor the CBC count for thesechanges. Creatinine, potassium, and BUN are unrelated to this medication.

• The nurse is performing an assessment on a female client who complainsof 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? 2 / 4

• Ascites
• Emboli
• Facial rash

4. Two hemoglobin S genes: 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 rashon the cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboliare 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 resultof the enzyme-linked immunosorbent assay (ELISA) has been positive.Whichdiagnostic study should the nurse be aware of before responding to the client?

• No further diagnostic studies are needed.
• A Western blot will be done to confirm these findings.
• The client probably will have a bone marrow biopsy done.

• A CD4+ cell count will be done to measure T helper lymphocytes.: 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 clientfor which clinical manifestation?

• Fever
• Cough
• Dyspnea at rest

4. Dyspnea on exertion: 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 thefirst sign. The cough begins as nonproductive and then progresses to productive.Later signs and symptoms include fever, dyspnea on exertion, and finally dyspneaat rest. 3 / 4

• A client with acquired immunodeficiency syndrome (AIDS) has a concurrentdiagnosis of

histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding?

• The histoplasmosis is resolving.
• The client has disseminated histoplasmosis infection.
• This is a side effect of the medications given to treat AIDS.

• The client probably has another infection that is developing.: 2.The client hasdisseminated

histoplasmosis infection.

Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respi- ratory 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 inter- ventions would be helpful in managing this symptom? Select all that apply.

• Keep liquids at the bedside.
• Place a towel over the pillowcase.
• Make sure the pillow has a plastic cover.

• Keep a change of bed linens nearby in case they are needed.
• Administer an antipyretic after the client has a spike in temperature.: 1. Keepliquids at the bedside.
• Place a towel over the pillowcase.
• Make sure the pillow has a plastic cover.
• 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 mayoffer 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 clientshould have liquids at the bedside to drink.

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