34Qw/exp *LOOKOVER**Immune---HIV/AIDS Zerweck
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis jirovecii pneumonia (PJP, PCP). Which nursing problem has the highest priority for this client? 1. Impaired oxygenation 2. Ineffective use of coping mechanisms 3. Poor nutrition 4. Activity tolerance
1 Rationale: Although all of these are nursing problems that are appropriate for the client with AIDS, according to Maslow's hierarchy of needs, impaired oxygenation is the priority nursing problem for the client with Pneumocystis jirovecii pneumonia
The nurse is caring for a client who is categorized as HIV-positive, acute infection. What would the nurse anticipate finding on the nursing assessment? 1. Fatigue, weight loss, night sweats 2. Confusion, disorientation, loss of coordination 3. Dyspnea, tachycardia on exertion, fever 4. Red, raised lesions on neck and face, fever
1 Rationale: An acute infection occurs when the primary condition is identified or the client has recently been infected. He may be asymptomatic at this time, or he may have symptoms of early nonspecific changes characterized by fatigue, weight loss, persistent fever, diarrhea, night sweats, and generalized lymphadenopathy. The symptoms noted in the remaining options are seen with chronic disease.
A client is diagnosed with an immunodeficiency disease. The nurse would understand what is characteristic of this condition? 1. Occurs when a client's body is unable to defend itself from an invading microorganism 2. Creates a severe, sudden problem that is characterized by increased vascular permeability 3. Is precipitated by the destruction of the normal lymphocytes in the attempt to reduce the serum level of the antigen 4. Is a condition in which the normal immune response is interrupted and the body cells do not recognize healthy tissue
1 Rationale: Immunodeficiency is the condition when the immune system is depressed, weak, or compromised and is unable to defend the body from invading microorganisms. Immunodeficiency may be primary if it is caused by an absence of immune cells or by poorly developed immune cells. It is secondary if it is caused by illnesses or treatment. A severe, sudden problem characterized by increased vascular permeability describes an anaphylactic reaction. The destruction of normal lymphocytes in the attempt to reduce the serum level of the antigen reflects phagocytosis as the white cells destroy the foreign protein. When the normal immune response is interrupted and body cells do not recognize healthy tissue, this is characteristic of an autoimmune condition.
A new mother tells the clinic nurse that her 6-week-old infant was born positive for human immunodeficiency virus (HIV). She asks the nurse how long her baby has to live. The nurse's response would be based on the knowledge that: 1. The antibodies present in the baby's blood may reflect the antibodies received from the mother at the time of birth, and further testing is required to validate the presence of HIV. 2. If antibodies were present at birth, the baby has acquired immunodeficiency syndrome (AIDS) and will probably become symptomatic within 6 months. 3. Because the baby is HIV positive and the virus is present this early, the prognosis is very poor; the majority of the children die within the first 3 years. 4. The antibodies detected at birth indicate the presence of HIV; the test does not indicate when the child will become HIV positive.
1 Rationale: It is important to give the mother as much hope as possible but still be realistic about the condition. There is no way to tell when or if the child will become HIV positive or develop active AIDS. Many infants seroconvert to HIV negative status. The HIV antibodies present at birth may have been received from the mother. If the virus is present and the infant begins to manufacture his or her own antibodies, then the infant is considered to be HIV positive and will probably develop AIDS. A series of tests should be done on the infant, one at the time of birth, repeated around 1 to 2 months, and another at 3 to 6 months to verify the presence of HIV. Most infants will begin antibody production by age 6 months if they are positive for HIV.
A client who is positive for the human immunodeficiency virus (HIV) has white raised lesions or plaques in his mouth on the inner cheek and tongue. Nystatin (Mycostatin) has been ordered. What will be important to teach the client about this medication? 1. Perform oral hygiene, then place medication in your mouth, and "swish and swallow." 2. Apply a small amount of the medication to each lesion; do not drink any oral fluids for 30 minutes. 3. Mix the medication with a small amount of water, and hold the solution in your mouth for about 5 minutes. 4. Place the medication under the tongue and allow it to absorb.
1 Rationale: The mycostatin must come in contact with all the lesions. It is easier to have the client swish it around the mouth than to try to place the medication on each lesion. The medication should not be mixed with water and should not be placed under the tongue. Candidiasis of the esophagus, mouth, and vagina is a common problem for the HIV client.
A client with AIDS has several cutaneous lesions identified as Kaposi's sarcoma. How will the nurse care for these areas? 1. Gently cleanse the areas, keeping them dry and free of abrasions. 2. Place sterile, saline-soaked gauze over the areas. 3. Apply a topical corticosteroid cream. 4. Decrease infection by applying an antibiotic ointment.
1 Rationale: There is no specific nursing care required for Kaposi's sarcoma lesions. Gently cleansing the area and protecting it from abrasive trauma, which could open the lesions, would be appropriate. Dressings, steroid cream, and antibiotic ointment are not indicated. Standard precautions should be followed when caring for the lesions.
It has been 3 years since seroconversion for a client who is positive for the human immunodeficiency virus (HIV). The client currently has CD4+ T cell count of 700. What would the nurse explain to the client regarding this information? 1. Currently the body is producing an adequate number of CD4+ T helper cells to protect against the virus. 2. The virus has stopped all replication and is in a dormant phase for an undetermined time. 3. The CD4+ T cell count means the virus is replicating and increased risk of opportunistic infections. 4. Antiretroviral medications are effectively protecting the client against an increase in the viral load.
1 Rationale: When the client is in the early stages, the body is able to produce enough CD4+ cells to maintain a normal level. The risk for opportunistic infection is low because of the normal CD4+ count. With this level of CD4+ cells the client is not experiencing an increased viral load.
Which assessment finding would lead the nurse to conclude that a female client may be HIV-positive? Select all that apply. 1. Unprotected intercourse 2. Frequent vaginal yeast infections in the last 12 months 3. Heavy menstrual flow 4. Difficulty becoming pregnant for the past 3 years 5. Nasal congestion and runny nose 6. Severe cramping and irregular periods
1.2 Rationale: Unprotected intercourse and frequent or persistent vaginal candidiasis may be the first symptoms of HIV in women. The body's diminished immune response permits overgrowth of Candida albicans. Menstrual problems and infertility are not generally indicative of HIV. Nasal congestion and a runny nose often indicate allergy.
A woman explains to the nurse that she thinks she has been exposed to HIV. However, she had a test 1 week after the exposure and the result was negative. What is most important for the nurse to explain to this client? 1. Make sure she understands the importance of safe sex practices, especially the use of condoms and contraceptive practices to prevent pregnancy. 2. Even though the client tested negative, she needs to have a series of follow-up blood tests because of the possibility of seroconversion. 3. It is important that she obtain counseling regarding the transmission of the virus and how she may protect herself and her partner. 4. The client should abstain from sexual activity for the next 3 months until the blood test confirms that she is negative for HIV.
2 Rationale: After initial infection, there is a window of seroconversion in which the virus begins to replicate and produce antibodies. The client may have a negative test result early in the window. When the body begins to produce antibodies against the virus, the test result will convert to a positive. She should not get pregnant, but contraceptives (oral birth control) do not protect her against human immunodeficiency virus (HIV). Abstaining from sexual activity is frequently unrealistic, and counseling would be beneficial but it is not the priority. Although emphasizing the importance of safe sex practices is correct, it is not the best response. The priority in this situation is the necessity for follow-up blood tests because of the initial negative test result.
After a repeat of the antibody test for the human immunodeficiency virus (HIV), a client continues to have a positive test result but is asymptomatic. The nurse understands which of the following about possible transmission of the virus by the client? 1. The client is infectious when symptoms are active. 2. The client is infectious for life. 3. The dormant virus is not infectious while the client is asymptomatic. 4. Laboratory tests should be done monthly to identify the infectious periods.
2 Rationale: HIV infection creates a chronic infectious state in the body; the infection is transmitted via blood and body fluids and transplacentally. The virus remains in the body, even when the client is asymptomatic. If the client has a positive test result on two consecutive occasions, he is HIV positive and will remain infectious for life.
The nurse is reviewing with a client, who is positive for human immunodeficiency virus, important implications of his antiretroviral therapy. In reviewing the medications the client currently takes, which one would cause the nurse the most concern? 1. Nonsteroidal antiinflammatory drugs (NSAIDs) 2. St. John's wort 3. Fexofenadine (Allegra) 4. Albuterol (Provental)
2 Rationale: St. John's wort should not be taken with any of the protease inhibitors, which is one of the most common classification of medications administered and one of the most effective. The other drugs listed are not contraindicated.
A nurse experiences a needle stick from an IM injection that was just administered to a client who is positive for human immunodeficiency virus (HIV). What would be the best nursing action? 1. Report the needle stick to the local public health department and inform any sexual contacts. 2. Notify the employee health center and report the circumstances regarding the needle stick. 3. Contact the personal physician to determine the risk factor for seroconversion and medications to prevent seroconversion. 4. Notify the unit manager and ask for advice regarding to whom, if anyone, you should report the incident.
2 Rationale: The employee health center should be notified of any needle stick or other exposure to infections, diseases, or conditions. Circumstances surrounding the incident will determine if any prophylactic treatment must be initiated. Reporting to the local public health department and notifying sexual contacts are not necessary at this point. The personal physician can be contacted, but the employee health center must still be notified. The unit manager should be notified, but the priority is to notify the employee health center.
The nurse is teaching a client about risk factors and prevention of transmission of human immunodeficiency virus (HIV). Which statement by the nurse is most accurate? 1. HIV can be transmitted by kissing or using the same eating utensils. 2. Unprotected oral sex with an infected partner is not advised. 3. Sharing an office with an HIV-positive person increases the risk of exposure to HIV. 4. Using the same bathroom as an infected family member puts you at risk of exposure to HIV.
2 Rationale: Unprotected oral sex with an HIV-positive person puts one at risk for exposure to the virus. The person receiving the semen is at increased risk; therefore, a condom should be worn for oral sex. Contact, such as casual kissing, sharing an office or bathroom, or sharing a kitchen and eating utensils, does not transmit the virus. The virus is not transmitted by saliva. The virus is transmitted primarily prenatally and in blood, semen, and breast milk.
The roommate of a client with acquired immunodeficiency syndrome (AIDS) comes to visit, follows the nurse out of the room, and says, "I am so scared I am going to get AIDS. I have been living with him." The nurse's response would be based on which principle? 1. The majority of people living with a client with AIDS are going to be HIV positive because of direct contact with the client. 2. The chance of getting AIDS is significantly decreased if the person has been in contact with a client with AIDS for less than 3 months. 3. HIV is spread by direct contact with the blood of an infected person and through sexual activity. 4. This is information the nurse cannot discuss with the roommate; therefore, the client should be referred to his primary care physician.
3 Rationale: According to the CDC, the primary route of transmission of the HIV that causes AIDS is through blood and body fluids. This option gives the roommate information so that he may determine whether he has been exposed. The other options are not true regarding HIV transmission.
A young woman has just received news of a positive test for human immunodeficiency virus (HIV). She does not want her sexual partner to be informed. What is the most appropriate nursing response to her decision? 1. Respect the client's decision, even if you disagree; it is her choice to make. 2. Let the client know that you have a legal responsibility to inform her partner. 3. Discuss with the client the ethical responsibility to inform all sexual partners. 4. Note the client's decision in the record for future reference.
3 Rationale: Although nurses are taught to respect clients' decisions and acknowledge their feelings, the ethical response to her comment would be to counsel her about her responsibility to notify all persons at risk. HIV is a reportable disease in some states. If it is legally reportable in the state, it is the responsibility of the public health department to contact the partner. In some states, a person who knowingly exposes another to HIV can face potential legal action.
The nurse would identify the occurrence of which situation that would indicate a need for further evaluation because of the client's increased risk for exposure to the human immunodeficiency virus (HIV)? 1. Frequent episodes of pneumonia 2. Recipient of three units of packed red cells 3. Frequent sexually transmitted diseases 4. Reports swollen glands, diarrhea, and fatigue
3 Rationale: Frequent sexually transmitted diseases would alert the nurse to the client's lack of protected sex and the possibility of multiple partners. Malaise, fatigue, swollen glands, and diarrhea are associated with the early symptoms of HIV+, not someone who would be at an increased risk for being infected. The virus is rarely transmitted by blood transfusions.
The nurse is teaching a client about preventing the spread of HIV. The client asks the nurse why women are at greater risk than men for development of HIV disease through intercourse. The nurse's response is based on which of the following? 1. Vaginal secretions contain prostaglandins that can suppress HIV replication. 2. Hormonal fluctuations make it more difficult for the woman's body to fight off viral infections. 3. The vagina has a greater amount of mucous membrane surface than the penis. 4. A woman's immune system is less competent during menses, which makes her more susceptible.
3 Rationale: Gender affects HIV transmission. HIV is most easily transmitted when infected body fluids come into contact with mucous membranes or nonintact skin. The vagina has much more mucous membrane than the penis. HIV is more easily transmitted from an infected male to an uninfected female than vice versa. Vaginal secretions do not contain prostaglandins to suppress HIV replication: only antiretroviral drugs can suppress replication. Female hormones associated with the menstrual cycle do not alter the woman's ability to fight off an HIV viral infection.
A woman is pregnant and is being seen in the clinic for the first time. She has a history of being HIV positive. What will be important for the nurse to teach this client? 1. Because the woman is HIV positive, the infant will not be infected with the virus. 2. All infants of HIV-positive mothers are negative for the virus at birth and convert within 6 weeks after delivery. 3. The woman should continue antiretroviral prophylaxis throughout pregnancy and will be scheduled for a cesarean delivery to reduce the risk of mother-to-child transmission of HIV. 4. The infant will be tested at birth and, if positive, can start breastfeeding and be started on the antiretroviral medications to prevent the growth of the HIV virus.
3 Rationale: The rate of mother-to-child transmission of HIV continues to decrease due to such interventions as increased HIV testing of pregnant women, elective cesarean delivery, use of antiretroviral prophylaxis, and avoidance of breastfeeding. HIV-exposed infants who test negative initially should undergo further testing at 1 to 2 months and at 4 to 6 months of age to exclude or identify HIV infection. Perinatally acquired HIV has declined with the use of preventive measures such as HIV counseling, voluntary testing practices, and highly active antiretroviral therapy (HAART). Breastfeeding is delayed until confirmatory testing is done. If the test is negative, prophylaxis is stopped and breastfeeding may start. If the test is positive, infants should be treated with antiretroviral prophylaxis for 6 weeks, and the mother should not breast-feed.
A client is worried he may have been exposed to AIDS. What will be important for the nurse to explain to this client? 1. Symptoms of AIDS will develop immediately in sexually active individuals. 2. Clients may remain asymptomatic for an indefinite period of time. 3. Symptoms of AIDS are usually seen before the client is found to be HIV-positive. 4. After exposure to the virus, symptoms may develop within 6 to 12 weeks or as late as 6 months.
4 Rationale: Clients usually have symptoms within 6 to 12 weeks of exposure; however, symptoms may not develop until 6 months after exposure. This is the period of seroconversion. The symptoms do not develop immediately in sexually active individuals. The client may remain asymptomatic for an undetermined period of time. The client may be HIV-positive for years before he is diagnosed as having AIDS.
A client who has been recently diagnosed as positive for the human immunodeficiency virus (HIV) asks the nurse about the medicine for the virus. The nursing response would be based on what concept? 1. The virus is frequently resistant to medication; therapy may be delayed to decrease client resistance. 2. Antiviral medications will be started when the client's CD4+ T cell counts are above 200 μL and the viral load is low. 3. Treatment will be started when the client begins to show evidence of seroconversion and development of symptoms 4. Antiviral therapy is individualized and will be based on the client's CD4+ T cell count and the viral load.
4 Rationale: Goals of antiretroviral therapy (ART) therapy are to decrease the viral load, increase or maintain the CD4+ T cell count, and delay the development of symptoms and opportunistic infections. ART usually is started when the CD4+ count drops below normal levels or the viral load is high. ART is not delayed to decrease development of resistance.
A client with a diagnosis of AIDS has developed P. jiroveci pneumonia (PJP, PCP). What will be important for the nurse to include in the nursing care plan? 1. Put a mask on the client whenever he has visitors in his room. 2. Explain to the client why he cannot go outside his room. 3. Wear a mask and gown when providing direct care to the client. 4. Wear a gown and gloves when assisting the client with personal hygiene.
4 Rationale: P. jiroveci pneumonia (PJP, PCP) is not easily transmitted from an infected person to a healthy person. The pathogen is frequently dormant in the body and is reactivated when the client's immune system is significantly depressed. There is no need for airborne or droplet precautions, but standard precautions must be strictly adhered to with this client.
A client who is positive for the human immunodeficiency virus (HIV) has been receiving antiviral medication for the past 3 months. He calls the clinic complaining of polydipsia, polyuria, and polyphagia. The nurse understands that these symptoms are most likely related to: 1. Diabetes-like symptoms caused by pancreatic infiltration by HIV virus 2. Allergic reaction to the non-nucleoside reverse-transcriptase inhibitor medications 3. Nonadherence with the antiviral medication regimen 4. Hyperglycemia caused by the protease inhibitor
4 Rationale: Protease inhibitors have been associated with hyperglycemia, new-onset diabetes, abrupt exacerbation of existing diabetes, and diabetic ketoacidosis. This usually occurs after 2 months of use. Polydipsia, polyuria, and polyphagia are symptoms attributed to the hyperglycemia, rather than an allergic reaction. These symptoms are not an indication of nonadherence to the antiviral regimen, although nonadherence can be attributed to many factors, including the complexity of the treatment regimen.
The nurse is reviewing with a certified nursing assistant (CNA) the care for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS) and has developed P. jiroveci pneumonia (PJP, PCP). Which of the following precautions would the nurse review with the CNA? 1. Strict handwashing 2. Airborne precautions 3. Contact precautions 4. Standard precautions
4 Rationale: The CDC recommends standard precautions for all clients; this is particularly important for the client with AIDS. Although strict handwashing is not an incorrect response, this should be performed when caring for all clients and is a part of standard precautions. Airborne precautions are not indicated for clients with opportunistic infections such as P. jirovecipneumonia (PJP, PCP). Protective isolation is indicated for clients who are severely immunocompromised
A client comes into the clinic with complaints of general malaise, increased lethargy, and headaches. An enzyme immunoassay (EIA) is positive for serum antibodies associated with the human immunodeficiency virus (HIV). What will be important for the nurse to discuss with the client? 1. The Western blot test will be done to determine the stage of HIV antibody reproduction. 2. It will be at least 5 years before possible conversion to acquired immune deficiency syndrome (AIDS). 3. Blood must be drawn to determine the level of the CD4+ T helper cells. 4. The test was positive; however, it must be repeated to verify the results.
4 Rationale: The EIA test was positive; however, it must be repeated. If the EIA is positive a second time, then more specific testing (Western Blot or immunofluorescence assay [IFA]) will be done before a diagnosis of HIV can be confirmed. The CD4+ T helper cells are monitored after the diagnosis to determine the client's response to the virus. Viral loads are done after the client is confirmed positive for HIV; it is not done for testing purposes.
The nurse is following up after therapy plans were discussed by the physician with the client who is considering antiviral therapy for the treatment after confirmation of a positive status for the human immunodeficiency virus (HIV) test. The client asks the nurse how long the therapy will last. The nurse bases a response on the understanding that therapy lasts: 1. Only 1 year 2. A minimum of 5 years 3. No longer than 10 years 4. A lifetime
4 Rationale: The antiretroviral treatment for HIV is a lifelong regimen of medications. As an advocate for the client, the nurse should explain this to the client and be certain that he is fully aware of this fact before treatment is initiated, because the drug therapy is complex and costly and may be toxic. The treatment does not cure the client but promotes an increase in CDT-4 cell count and a decrease in the viral load.
