Chapter 36: Management of Patients With Immune Deficiency Disorders QUESTIONS
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
A) Administer antidiarrheal medications on a scheduled basis, as ordered. (Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis, provided the patient's diarrhea is not caused by an infectious microorganism.)
A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test?
A) Arrange for a portable x-ray machine to be used. (A patient who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the patient's room.)
An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL, and the nurse recognizes the patient's increased risk for Mycobacterium aviumcomplex (MAC disease). The nurse should anticipate the administration of what drug?
A) Azithromycin (HIV-infected adults and adolescents should receive chemoprophylaxis against disseminated Mycobacterium avium complex [MAC disease] if they have a CD4+ count less than 50 cells/µL. Azithromycin [Zithromax]or clarithromycin [Biaxin] are the preferred prophylactic agents.)
A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.
A) Current medication regimen B) Identification of patient's support system C) Immune system function E) History of sexual practices (Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function and sexual history.)
Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV?
A) Gay, bisexual, and other men who have sex with men (Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 2% of the population but 61% of the new infections.)
A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication?
A) HIV encephalopathy (HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions.)
A nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
A) Ineffective Airway Clearance (Airway and breathing take top priority over the other listed concerns.)
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurse's choice of educational interventions?
A) Many older adults do not see themselves as being at risk for HIV infection. (It is known that many older adults do not see themselves as being at risk for HIV infection.)
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
A) Perianal region and oral mucosa (The nurse should inspect all the patient's skin surfaces and mucous membranes, but the oral mucosa and perianal region are particularly vulnerable to skin breakdown and fungal infection.)
The nurse's plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk?
A) Providing thorough oral care before and after meals (Thorough mouth care has the potential to prevent or limit the severity of this infection.)
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
A) Serum albumin level B) Weight history D) Body mass index E) Blood urea nitrogen (BUN) level (Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the patients ability to purchase and prepare food is assessed. Weight history [such as changes over time] anthropometric measurements; and blood urea nitrogen [BUN] serum protein, albumin, and transferrin levels provide objective measurements of nutritional status.)
A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?
A) Teach the patient guided imagery. (Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue.)
A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions?
B) Educational programs that focus on control and prevention
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
A) Utilize a pressure-reducing mattress. (Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown.)
A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?
C) Many patients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks. (The nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers.)
A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patient's gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis?
B) Diarrhea (Diarrhea is a problem in 50% to 60% of all AIDS patients.)
A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold?
B) 200 cells/mm3 of blood (When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.)
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
B) Addressing possible barriers to adherence (ART is highly dependent on adherence to treatment, and the nurse should proactively address this.)
A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patient's CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle?
B) Attachment (During the process of attachment, glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane.)
A patient who has AIDS has been admitted for the treatment of Kaposi's sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
B) Impaired Skin Integrity Related to Kaposi's Sarcoma (Kaposi's sarcoma [KS] is a disease that involves the endothelial layer of blood and lymphatic vessels.)
A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education?
B) Importance of personal hygiene (Infection control is of high importance in patients living with HIV, thus personal hygiene is paramount.)
A hospital nurse has experienced percutaneous exposure to an HIV-positive patient's blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next?
B) Report to the emergency department or employee health department. (After initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. Flushing is recommended.)
A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patient's diarrhea?
B) Sandostatin (Therapy with octreotide acetate [Sandostatin], a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea.)
A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
B) Tachypnea and restlessness (In prioritizing care, the pneumonia would be assessed first by the nurse. Tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority.)
A patient is in the primary infection stage of HIV. What is true of this patient's current health status?
B) The patient is infected with HIV but lacks HIV-specific antibodies. (The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection.)
A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in AIDS patients by increasing body fat stores?
C) Megestrol (Megestrol acetate [Megace], a synthetic oral progesterone preparation, promotes significant weight gain. In patients with HIV infection, it increases body weight primarily by increasing body fat stores.)
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurse's most appropriate action?
C) Place the patient on respiratory isolation and inform the physician. (These signs and symptoms are suggestive of tuberculosis prompt assessment and treatment is necessary.)
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurse's best response?
C) AIDS isn't transmitted by casual contact. (AIDS is commonly transmitted by contact with blood and body fluids. Patients, family, and friends must be reassured that HIV is not spread through casual contact.)
The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?
C) Can you tell me what concerns you most about dying? (The nurse can help the patient verbalize feelings and identify resources for support. The nurse should respond with an open-ended question to help the patient to identify fears about being diagnosed with a life-threatening chronic illness.)
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
C) Keep the patient's bed linens free of wrinkles. (Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing.)
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
C) The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
A patient's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patient's immune response. This physiologic state is known as which of the following?
C) Viral set point (The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a steady state of infection that lasts for years.)
A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse should expect the primary care provider to order what test to confirm the EIA test results?
C) Western blot test (The Western blot test detects antibodies to HIV and is used to confirm the EIA test results.)
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
D) Hold the condom by the cuff upon withdrawal.
An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurse's best response?
D) It's possible that your baby could contract HIV, either before, during, or after delivery. (Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breast-feeding.)
A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
D) Obtain a stool culture to identify possible pathogens. (A stool culture should be obtained to determine the possible presence of microorganisms that cause diarrhea. Patients should generally avoid raw fruit when having diarrhea.)
A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurse's best response?
D) Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
D) Pneumocystis pneumonia (The most common life-threatening infection in those living with AIDS is Pneumocystis pneumonia [PCP]caused by P. jiroveci [formerly carinii])
A patient's current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide based on the patient's medication regimen?
D) Take this medication without regard to meals. (Many NRTIs exist, but all of them may be safely taken without regard to meals.)
A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what?
D) The patient has been infected with HIV. (Positive test results indicate that antibodies to the AIDS virus are present in the blood.)