Chapter 19: Care of Patients with HIV Disease and Other Immune Deficiencies
A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? a) Fluconazole (Diflucan) b) Trimethoprim/sulfamethoxazole (Bactrim) c) Rifampin (Rifadin) d) Acyclovir (Zovirax)
Correct Answer: a Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent.
A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? a) "With this treatment, I probably cannot spread this virus to others." b) "This treatment does not kill the virus." c) "This medication prevents the virus from replicating in my body." d) "Research has shown the effectiveness of this therapy if I do not forget to take any doses."
Correct Answer: a HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids. HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance.
Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? a) The dietary worker hands the disposable meal trays to the LPN assigned to the client. b) The social worker encourages the client to verbalize about stressors at home. c) A member of the housekeeping staff thoroughly cleans and disinfects the hallways near the client's room. d) The health care provider orders vital signs, including temperature, every 8 hours.
Correct Answer: a The dietary worker giving the meal tray to the LPN limits the number of health care personnel entering the room, thus reducing the risk for infection. Verbalizing stressors does not reduce the risk for infection. Cleaning of bathrooms, not hallways, at least once daily by housekeeping staff reduces risk for infection. Vital signs, including temperature, should be taken every 4 hours to detect potential infection, but this does not reduce the risk for infection.
In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? a) "Have you had sex with men or women or both?" b) "I hope you use condoms to protect your partners." c) "You must tell me all of your partners' names, so I can let them know about possibly having AIDS." d) "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."
Correct Answer: a The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate. "I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. Asking for information in the name of the public health department is not straightforward, and the tone of this entire statement is judgmental.
The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery by his family? a) "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" b) "Is there somewhere private in the home where we can go and talk?" c) "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." d) "It is your duty to protect your family members from getting AIDS."
Correct Answer: b A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.
A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client? a) Clean toothbrushes once a week. b) Bathe daily using an antimicrobial soap. c) Eat salad at least once a day. d) Wash dishes in cool water.
Correct Answer: b Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin. Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. Salads and raw fruits and vegetables could be contaminated and should be avoided. Dishes should be washed in hot, soapy water or in a dishwasher.
Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? a) "I told family members they need to wash their hands when they enter and leave the room." b) "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." c) "Yes, I understand the reasons why I have to wear gloves when I bathe the client." d) "The client's spouse told me she got HIV from a blood transfusion."
Correct Answer: b Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse. Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.
Which factor relates most directly to a diagnosis of primary immune deficiency? a) History of viral infection b) Full-term infant surfactant deficiency c) Contact with anthrax toxin d) Corticosteroid therapy
Correct Answer: b Genetic mutation causes surfactant deficiency; this is a primary immune deficiency. Viral infection can cause a secondary immune deficiency. Anthrax and medical therapy are examples of a secondary immune deficiency.
The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? a) Administer antibiotics as prescribed. b) Transfuse ordered packed red blood cells. c) Teach pursed-lip breathing. d) Encourage increased fluid intake.
Correct Answer: b Packed red blood cells increase hemoglobin molecules; this increases sites at which oxygen can attach and improves gas exchange. Antibiotics treat infection; they do not improve oxygenation. Mouth breathing does not improve oxygenation related to anemia. Fluid intake does not have an effect on improving oxygenation.
When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? a) "Condoms should be used when lesions are present on the penis." b) "Always position the condom with a space at the tip of an erect penis." c) "Make sure it fits loosely to allow for penile erection." d) "Use adequate lubrication, such as petroleum jelly."
Correct Answer: b Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom. Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only.
A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? a) Collaborate with the client to select foods that are high in calories. b) Provide oral care to the client before meals to enhance appetite. c) Assess the perianal area every 8 hours for signs of skin breakdown. d) Discuss the need to avoid foods that are spicy or irritating.
Correct Answer: b Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants. Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice; these actions should be done by licensed staff.
The nurse is assigned to care for four clients. Which client does the nurse assess first? a) Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm b) Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature c) Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia d) Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count
Correct Answer: b The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring; the client is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated. Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.
A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? a) "This will not make any difference in the viral load." b) "Blood concentrations will be decreased, which will lead to increased viral replication." c) "If only one dose of medication is missed, this will not make a difference." d) "This will cause an increase in opportunistic infections."
Correct Answer: b When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). When this concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. Therefore, it is critical to ensure that highly active antiretroviral therapy (HAART) doses are not missed, delayed, or administered in lower-than-prescribed dosages in the inpatient setting. Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART.
A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? a) Obtain a 12-lead electrocardiogram (ECG). b) Call for a portable chest x-ray. c) Obtain blood cultures from two sites. d) Give cefazolin (Kefzol) 500 mg IV.
Correct Answer: c Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic. A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out.
The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? a) "When I injected heroin, I was exposed to HIV." b) "I don't understand how the antiretroviral drugs work." c) "I remember to take my antiretroviral drugs almost every day." d) "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."
Correct Answer: c Because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains, it is important that clients take these drugs consistently. The nurse should immediately assess the reasons why the client does not take the medications daily and then should implement a plan to improve adherence. The nurse should assess whether the client is still injecting drugs and should make certain the client understands the risks for infection with another strain of HIV or other bloodborne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. The nurse must provide further education about how the medications work and assess how the lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.
In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? a) Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma b) Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency c) Potential for infection transmission related to recurring opportunistic infections d) High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans
Correct Answer: c Protecting the client from further opportunistic infection such as Candida albicans is a priority. Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be the secondary concern because Candida albicans causes the mouth sores. Nutrition will be affected because of Candida albicans; however, it is not a priority.
The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? a) "I need to know my HIV status, so I must get tested before caring for any clients." b) "Putting on a gown and gloves will cover up the itchy sores on my elbows." c) "Washing my hands and putting on a gown and gloves is what I must do before starting care." d) "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."
Correct Answer: c Standard Precautions include whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes. Knowing HIV status is important for preventing transmission of HIV, but is not a Standard Precaution. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.
A client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? a) Therapeutic highly active antiretroviral therapy (HAART) level b) Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot c) Positive Papanicolaou (Pap) test d) Improved CD4+ T-cell count and reduced viral load
Correct Answer: d Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication. Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication.
Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia? (Select all that apply.) a) Change the decorations in the home according to the season. b) Put the bed close to the window. c) Write out detailed instructions, and have the client read them over before performing a task. d) Ask the client what time he or she prefers to shower or bathe. e) Mark off the days of the calendar, leaving open the current date.
Correct Answers: a, b, d, e Changing decorations according to the season and using a calendar to mark off the days will help to keep the client oriented. Keeping the bed close to the window may help keep the client oriented. The client should be included in planning the daily schedule. Directions should be short and uncomplicated.
Which factors are possible transmission routes for human immune deficiency virus (HIV)? (Select all that apply.) a) Breast-feeding b) Anal intercourse c) Mosquito bites d) Toileting facilities e) Oral sex
Correct Answers: a, b, e HIV can be transmitted via breast milk from an infected mother to the child. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum, but it also tears the mucous membranes, making infection more likely. Oral sexual contact exposes the mucous membranes to infected semen or vaginal secretions. HIV is not spread by mosquito bites or by other insects. HIV is not transmitted by casual contact, and sharing toilet facilities does not allow transmission of HIV.
The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing? (Select all that apply.) a) "I am 78 years old, and I was treated and cured of syphilis many years ago." b) "In 1986, I received a transfusion of platelets." c) "Seven years ago, I was released from a penitentiary." d) "I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." e) "At 68, I am going to get married for the fourth time."
Correct Answers: a, c, e People who have had a sexually transmitted disease should be tested. People who are in or have been in correctional institutions such as jails or prisons and people who are planning to get married should be tested for HIV. HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985. People who have used injectable drugs (not marijuana) should be tested.