Chapter 20

The nurse is teaching a client about using a condom effectively. Which statement made by the client indicates an understanding of the teaching? 1. "A condom can be used up to a month after the expiration date." 2. "I can use the same condom if I have sex twice in one night as long as it is with the same person." 3. "As long as I apply the condom before ejaculation, we are having safe sex." 4. "I should withdraw from my partner by holding the condom against the base of the penis."

"I should withdraw from my partner by holding the condom against the base of the penis."

The nurse is teaching a male client who is positive for human immunodeficiency virus (HIV) regarding risks of sexually transmitting the virus to a partner. Which statement made by the client indicates a need for further teaching? 1. "I can be infected with HIV by having vaginal intercourse." 2. "It will be difficult for me to infect my male partner during sex." 3. "I cannot get HIV from kissing my partner who is infected with HIV." 4. "Semen has a higher amount of the viral load than vaginal fluid."

"It will be difficult for me to infect my male partner during sex."

The nurse is teaching a client who is about to undergo antiretroviral therapy (ART). Which statement made by the client indicates an understanding regarding the goal of therapy?

"The medications will delay development of AIDS."

The nurse is teaching an unlicensed assistive personnel (UAP) about caring for a client with human immunodeficiency virus (HIV). Which statement made by the UAP requires correction by the nurse? 1. "This client should be in place in an isolation room." 2. "I will wear gloves when changing the client's sheets." 3. "I can't take care of the client because I have cold symptoms." 4. "I will wash my hands before and after caring for the client."

"This client should be in place in an isolation room."

The nurse is caring for a client with human immunodeficiency virus (HIV) who states, "I cannot afford to take all of these medications anymore." Which response by the nurse is best?

"We can have someone come speak to you about financial resources."

These are the seven steps in the human immunodeficiency virus (HIV) replication process. Place them in chronological order starting from the first step.

(1) The first is binding to the CD4 receptor of the host cell. Cellular chemokine receptor type 5 (CCR5) antagonist drugs act here to block HIV attachment. (2) Binding leads to fusion of the HIV envelope (membrane) and host cell membrane. Fusion inhibitor drugs act here. (3) After fusion, the HIV capsid (which encloses genetic material of the virus) is released into the host cell. HIV uses its enzyme reverse transcriptase to convert its RNA to HIV DNA. The new HIV DNA then enters the host cell's nucleus. Non-nucleotide reverse transcriptase inhibitors (NNRTIs) and the nucleoside reverse transcriptase inhibitors (NRTIs) act here. Inhibitors of reverse transcriptase that act here were the first anti-HIV drugs developed. (4) HIV releases the enzyme integrase, which incorporates its HIV DNA into the host cell's DNA. Integrase inhibitors act here. (5) HIV then uses the machinery of the host cell to replicate long chains of HIV proteins for building more HIV. (6) Packaging of HIV RNA and HIV proteins within a viral envelop created from part of the cell membrane occurs next. (7) Immature, noninfectious HIV then buds from the host cell. It releases enzyme protease to cut the HIV protein chains into their shorter functional forms. Mature, infectious HIV is then formed from these proteins. Protease inhibitors, which are potent antiviral medications, block this critical step.

The nurse is teaching a client about drug resistance in individuals with human immunodeficiency virus (HIV). Which statement made by the client indicates an understanding of the teaching? 1. "I have class during one of my scheduled doses, so I can take it later that day." 2. "I am going to set my alarm to alert me each time I need to take the medication." 3. "If I have side effects from the medication, it is okay if I don't take the dose that day." 4. "I am supposed to take medication four times daily, but I am going to cut back while I am out of town."

. "I am going to set my alarm to alert me each time I need to take the medication."

The nurse is caring for a client with acquired immune deficiency syndrome (AIDS) who is symptomatic. Which clinical manifestations will the nurse expect to find in this client? Select all that apply. 1. Dyspnea 2. Weight gain 3. Fever 4. Diarrhea 5. Night sweats

1. Dyspnea 3. Fever 4. Diarrhea 5. Night sweats

The nurse is teaching the family of a client with human immunodeficiency virus (HIV) about preventing infection. Which information will the nurse include in the teaching? Select all that apply. . Wash dishes and cooking utensils in cold, soapy water 2. Use a disinfectant wash cloth to clean the refrigerator 3. Rinse and wash contaminated clothing separately 4. Dispose of contaminated articles in a sealed plastic bag and place in the trash 5. Dispose of sharp objects by using a red biohazard container if available

2. Use a disinfectant wash cloth to clean the refrigerator 3. Rinse and wash contaminated clothing separately 4. Dispose of contaminated articles in a sealed plastic bag and place in the trash 5. Dispose of sharp objects by using a red biohazard container if available

The nurse is preparing to administer diphenoxylate hydrochloride 5 mg by mouth to a client with diarrhea. Available is diphenoxylate hydrochloride 2.5 mg tablets. How many tablets will the nurse administer? Enter the numeral only.

2.5 mg available and you need 5mg. Multiply 2.5 by two with equals 5mg

The nurse is identifying individuals who require routine testing for human immunodeficiency virus (HIV). Which client does not require routine testing? 1. A 10-year-old female who was sexually assaulted 2. A 17-year-old male who has had three sexual partners in the last year 3. A 30-year-old female who is 8 weeks pregnant 4. A 70-year-old male who is in a monogamous relationship

A 70-year-old male who is in a monogamous relationship

The nurse is caring for a group of clients. Which client will the nurse see first? 1. A client who has HIV and presents with 100.1° temperature 2. A client with multiple sclerosis who complains of weakness 3. A client who reports of tenderness to cervical lymph nodes 4. A client with rheumatoid arthritis (RA) who reports of joint pain

A client who has HIV and presents with 100.1° temperature

The nurse is teaching a client with human immunodeficiency virus (HIV) about indinavir sulfate. Which of the following is most important for the nurse to include in the teaching? 1. Instruct the client to refrain from driving if dizziness occurs 2. Instruct the client to report flu-like symptoms 3. Monitor for severe rash 4. Drink at least 48 ounces of liquids in 24 hr

Drink at least 48 ounces of liquids in 24 hr

The nurse is administering lamivudine/zidovudine (Combivir) to a client with human immunodeficiency virus (HIV). Which of the following should the nurse report to the health-care provider? 1. Dizziness 2. Bleeding 3. Nausea and vomiting 4. Flu-like symptoms

Flu-like symptoms

A client who has a previous allergy to sulfa drugs came in with an infection. Which prescription will the nurse question?

Fosamprenavir calcium

The nurse is caring for a client with cytomegalovirus (CMV). Which medication should the nurse expect to administer? 1. Ganciclovir (Cytovene) 2. Trimethoprim-sulfamethoxazole (Bactrim) 3. Acyclovir (Zovirax) 4. Ethambutol (Myambutol)

Ganciclovir (Cytovene)

The nurse is caring for a client with acute retroviral syndrome. Which clinical manifestation can the nurse expect to document? 1. Seizures 2. Constipation 3. Lymphadenopathy 4. Skin lesions

Lymphadenopathy

The nurse is caring for a client with late-stage acquired immunodeficiency syndrome (AIDS) who develops oral candidiasis. Which intervention will the nurse implement?

Provide oral care with a soft toothbrush

The nurse is caring for a client with cytomegalovirus (CMV). Which symptom experienced by a client is a complication of this disease process? 1. Diarrhea 2. Fever 3. Retinitis 4. Fatigue

Retinitis

The nurse is teaching a group of individuals about preventing human immunodeficiency virus (HIV) through sexual contact. Which method will the nurse include in the teaching? Select all that apply. 1. Routine use of condoms 2. Get an annual HIV vaccination 3. Lessen the number of sexual partners 4. Limit sexual contact to oral sex 5. Abstain from any form of sexual contact

Routine use of condoms Lessen the number of sexual partners Abstain from any form of sexual contact

The nurse is administering parenteral medications to a client who is HIV positive. Which procedure performed by the nurse would require the charge nurse to intervene? 1. The nurse uses hand rub then wears gloves to administer the medication 2. The nurse performs hand hygiene before and after medication administration 3. The nurse recaps the needle after administering the medication 4. The nurse disposes of the syringe and needle in the sharps container

The nurse recaps the needle after administering the medication

The charge nurse is making assignments for the shift. Which nurse should not be assigned to care for a client with human immunodeficiency virus (HIV)? 1. The nurse who has symptoms of a cold 2. The nurse taking insulin for hyperglycemia 3. The nurse with hypothyroidism 4. The nurse with multiple sclerosis (MS)

The nurse who has symptoms of a cold

The nurse is caring for a client with human immunodeficiency virus (HIV) who is taking antiretroviral therapy (ART). What viral serum level is indicative of an effective treatment? 1. Viral load of 15 copies/mL 2. Viral load equal to 240 copies/mL 3. Viral load more than 1,000 copies/mL 4. Viral load of 100 copies/mL

Viral load of 15 copies/mL This level is indicative of effective treatment; optimal viral load should be less than 20 to 75 copies/mL.

The nurse is providing education about prevention of infection to a client with human immunodeficiency virus (HIV). Which information will the nurse include in the education? 1. Eat foods from buffets 2. Reuse dishes without washing 3. Wash hands frequently 4. Drink water from kitchen faucet

Wash hands frequently

The nurse accidently stuck herself with a used needle after administering medication to a client who is positive for human immunodeficiency virus (HIV). Which action should the nurse take first?

Wash the exposure site with soap and water

The nurse caring for a client with human immunodeficiency virus (HIV) experiences a needlestick injury. Which step should the nurse take first? 1. Apply a bandage to the area 2. Wash the site with soap and water 3. Take a dose of prophylactic medication 4. Notify employee health

Wash the site with soap and water

After exposure, how soon do human immunodeficiency virus (HIV) antibodies become present in the body? 1. Within 3 months 2. Within 4 months 3. Within 5 months 4. Within 6 months

Within 3 months

The nurse is caring for a client who admits to using intravenous drugs. The nurse will provide instruction on which parenteral transmission of HIV?

A new sterile needle should be used each time

The nurse is teaching an older adult about transmission of the human immunodeficiency virus (HIV). Which statement made by the client indicates an understanding of the teaching?

"I can contract HIV from having sex with someone who has HIV."

The nurse is caring for a group of clients. Which should the nurse see first? 1. A patient with HIV who reports a sore throat 2. A patient with HIV with a temperature of 98.1 3. A patient with HIV who refused to eat lunch 4. A patient with HIV who is emotionally distressed

A patient with HIV who reports a sore throat

The nurse is providing education about HIV prevention to a group of older adults. Which statement indicates a need for further teaching? 1. "I use recreational drugs, but I shoot myself with clean needles each time." 2. "I no longer need to use a condom because people my age can't get pregnant." 3. "I should get tested for HIV since I have sex with multiple partners." 4. "I am at risk for HIV because my immune system function has declined."

"I no longer need to use a condom because people my age can't get pregnant."

The nurse is providing education about human immunodeficiency virus (HIV) to a group of clients. Which method of transmission will the nurse include in the teaching? Select all that apply. 1. Blood 2. Sharing dishes 3. Rectal fluids 4. Breast milk 5. Vaginal fluid

1. Blood 3. Rectal fluids 4. Breast milk 5. Vaginal fluid

The nurse is reviewing the morning laboratory report. Which CD4 T lymphocyte count is expected in a client with acquired immunodeficiency syndrome (AIDS)? 1. CD4 count below 200 2. CD4 count between 200 and 400 3. CD4 count between 500 and 700 4. CD4 count above 700

CD4 count below 200

The nurse is caring for a client with human immunodeficiency virus (HIV) who reports yellow-white patches in the mouth. The nurse knows this is a common finding in which condition? 1. Cytomegalovirus 2. Mycobacterium Avium Complex 3. Candida albicans 4. Pneumocystis pneumonia

Candida albicans

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) wasting syndrome. Which clinical manifestations will the nurse expect to find?

Chronic diarrhea

What do you call the time elapsed between exposure to a pathogenic organism and the appearance of signs and symptoms? 1. Opportunistic infection 2. Symptomatic stage 3. HIV replication 4. Clinical latency stage

Clinical latency stage

The health-care provider prescribes 500 mL of D5½ sodium chloride to infuse over 3 hr. At what rate will the nurse set the infusion pump? Round to the nearest whole number. Enter the numeral only.

Divide 500 by 3, which equals 166.66. Rounding to the nearest whole number equals 167.

During infection, which antibody is produced initially?

Immunoglobulin M (IgM)

Which client action is a major cause for developing a drug resistance during treatments to suppress human immunodeficiency virus (HIV) proliferation?

Nonadherence to medication treatments

The nurse is assessing a client with acquired immunodeficiency syndrome (AIDS) who is diagnosed with Kaposi sarcoma. Which assessment will the nurse document? 1. Purple lesions on the neck 2. Pale conjunctiva 3. Butterfly rash on the face 4. Facial edema

Purple lesions on the neck

A client taking rilpivirine reports a side effect. Which side effect will be most concerning to the nurse? 1. Diarrhea 2. Rash 3. Nausea 4. Insomnia

Rash

The nurse is caring for a pregnant client who states that she has had multiple sexual partners. Which interventions will the nurse implement first?

Recommend HIV testing and counseling

The unlicensed assistive personnel reports vital signs to the nurse caring for a client with human immunodeficiency virus (HIV). Which vital sign is most concerning to the nurse? 1. Blood pressure 108/62 2. Heart rate 86 3. Respiration rate 16 4. Temperature 101.8

Temperature 101.8

The nurse is providing teaching for a client with wasting syndrome. Which should the nurse include in the teaching? 1. Instruct the client to numb painful oral sores with popsicles 2. Discourage the client to exercise 3. Encourage the client to eat spicy foods 4. Teach the patient to follow a high-residue diet

Instruct the client to numb painful oral sores with popsicles

The nurse is caring for a client with human immunodeficiency virus (HIV) who is experiencing central nervous system (CNS) changes. Which intervention will the nurse implement first? 1. Encourage the family to stay at the beside 2. Place the side rails up with call light in reach 3. Encourage increased caloric intake 4. Consult a dietitian

Place the side rails up with call light in reach