Chapter 36 updated
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. B) Have the patient wear a mask to the x-ray department C) Ensure that the radiology department has been disinfected prior to the test. D) Send the patient to the x-ray department, and have the staff in the department wear masks.
A (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. This confers more protection than disinfecting the radiology department or using masks.)
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. B) Encourage the patient to eat three balanced meals and a snack at bedtime. C) Increase the patient's oral fluid intake. D) Encourage the patient to increase his or her activity level.
A (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. Increased oral fluid may exacerbate diarrhea; IV fluid replacement is often indicated. Small, more frequent meals may be beneficial, and it is unrealistic to increase activity while the patient has frequent diarrhea.)
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 B) Impaired Oral Mucous Membranes C) Imbalanced Nutrition: Less than Body Requirements D) Activity Intolerance
A (Although all these nursing diagnoses are appropriate for a patient with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the patient with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns.)
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. B) Limit the patient's physical activity. C) Apply antibiotic ointment to dependent skin surfaces. D) Avoid contact with synthetic fabrics.
A (Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Activity should be promoted, not limited, and contact with synthetic fabrics does not necessary threaten skin integrity. Antibiotic ointments are not normally used unless there is a break in the skin surface.)
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 B) Recreational drug users C) Blood transfusion recipients D) Health care providers
A (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. This exceeds the incidence among drug users, health care workers, and transfusion recipients.)
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 B) B-cell lymphoma C) Kaposi's sarcoma D) Wasting syndrome
A (HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations.)
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 B) Administering prophylactic antibiotics C) Promoting nutrition and adequate fluid intake D) Applying skin emollients as needed
A (Thorough mouth care has the potential to prevent or limit the severity of this infection. Antibiotics are irrelevant because of the fungal etiology. The patient requires adequate food and fluids, but these do not necessarily prevent candidiasis. Skin emollients are not appropriate because candidiasis is usually oral.)
An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/μL, and the nurse recognizes the patient's increased risk for Mycobacterium avium complex (MAC disease). The nurse should anticipate the administration of what drug? A) Azithromycin B) Vancomycin C) Levofloxacin D) Fluconazole
A 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. Vancomycin, levofloxacin, and fluconazole are not prophylactic agents for MAC.
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. B) Many older adults are not aware of the difference between HIV and AIDS. C) Older adults tend to have more sex partners than younger adults. D) Older adults have the highest incidence of intravenous drug use.
A It is known that many older adults do not see themselves as being at risk for HIV infection. Knowledge of the relationship between HIV infection and AIDS is not known to affect the incidence of new cases. The statements about sex partners and IV drug use are untrue.
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. B) Give the patient more control of her antiretroviral regimen. C) Increase the patient's activity level. D) Collaborate with the patient's physician to obtain an order for hydromorphone.
A Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue. Increased activity may be of benefit, but for other patients this may exacerbate feelings of anxiety or loss. Granting the patient control has the potential to reduce anxiety, but the patient is not normally given unilateral control of the ART regimen. Hydromorphone is not used to treat anxiety
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 B) Sacral region and lower abdomen C) Scalp and skin over the scapulae D) Axillae and upper thorax
A 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
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 D) Genetic risk factors for HIV E) History of sexual practices
A,B,C,E Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function and sexual history. HIV does not have a genetic component.
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 C) White blood cell count D) Body mass index E) Blood urea nitrogen (BUN) level
A,B,D,E 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 patient's ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment
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? A) Acute Abdominal Pain B) Diarrhea C) Bowel Incontinence D) Constipation
B (Diarrhea is a problem in 50% to 60% of all AIDS patients. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply.)
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? A) Integration B) Attachment C) Cleavage D) Budding
B 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. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle
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? A) Oral temperature of 100°F B) Tachypnea and restlessness C) Frequent loose stools D) Weight loss of 1 pound since yesterday
B (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. Weight loss of 1 pound is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 100°F is not considered a fever and would not be the first issue addressed.)
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? A) Lifestyle actions that improve immune function B) Educational programs that focus on control and prevention C) Appropriate use of standard precautions D) Screening programs for youth and young adults
B (Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions apply to very few cases of HIV infection.)
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? A) 75 cells/mm3 of blood B) 200 cells/mm3 of blood C) 325 cells/mm3 of blood D) 450 cells/mm3 of blood
B (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? A) Promoting appropriate use of complementary therapies B) Addressing possible barriers to adherence C) Educating the patient about the pathophysiology of HIV D) Teaching the patient about the need for follow-up blood work
B ART is highly dependent on adherence to treatment, and the nurse should proactively address this. Blood work is necessary, but this will not have a direct bearing on the success or failure of treatment. Complementary therapies are appropriate, but are not the main factor in successful treatment. The patient may or may not benefit from teaching about HIV pathophysiology
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? A) Flush the wound site with chlorhexidine. B) Report to the emergency department or employee health department. C) Apply a hydrocolloid dressing to the wound site. D) Follow up with the nurse's primary care provider.
B 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, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended. Following up with the nurse's own primary care provider would require an unacceptable delay.
A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A) Appropriate use of prophylactic antibiotics B) Importance of personal hygiene C) Signs and symptoms of wasting syndrome D) Strategies for adjusting antiretroviral dosages
B Infection control is of high importance in patients living with HIV, thus personal hygiene is paramount. This is a more important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be independently adjusted. Prophylactic antibiotics are not normally prescribed unless the patient's CD4 count is below 50
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? A) Risk for Disuse Syndrome Related to Kaposi's Sarcoma B) Impaired Skin Integrity Related to Kaposi's Sarcoma C) Diarrhea Related to Kaposi's Sarcoma D) Impaired Swallowing Related to Kaposi's Sarcoma
B Kaposi's sarcoma (KS) is a disease that involves the endothelial layer of blood and lymphatic vessels. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome
A patient is in the primary infection stage of HIV. What is true of this patient's current health status? A) The patient's HIV antibodies are successfully, but temporarily, killing the virus. B) The patient is infected with HIV but lacks HIV-specific antibodies. C) The patient's risk for opportunistic infections is at its peak. D) The patient may or may not develop long-standing HIV infection.
B The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection is certain. Opportunistic infections emerge much later in the course of the disease.
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? A) Zithromax B) Sandostatin C) Levaquin D) Biaxin
B Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. Zithromax, Levaquin, and Biaxin are not used to treat chronic severe diarrhea
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? A) "Do you think that you might already have HIV?" B) "Don't worry. Your immune system is likely very healthy." C) "AIDS isn't transmitted by casual contact." D) "You can't contract AIDS in a hospital setting."
C (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. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV infection.)
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors? A) The nurse wears face protection, gloves, and a gown when irrigating a wound. B) The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves. C) The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. D) The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.
C (Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same patient. Each of the other listed actions adheres to standard precautions.)
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? A) Another EIA test B) Viral load test C) Western blot test D) CD4/CD8 ratio
C (The Western blot test detects antibodies to HIV and is used to confirm the EIA test results. The viral load test measures HIV RNA in the plasma and is not used to confirm EIA test results, but instead to track the progression of the disease process. The CD4/CD8 ratio test evaluates the ratio of CD4 and CD8 cells but is not used to confirm results of EIA testing.)
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? A) "Would you like me to have the chaplain come speak with you?" B) "You'll learn much about the promise of a cure for HIV." C) "Can you tell me what concerns you most about dying?" D) "You need to maintain hope because you may live for several years."
C (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. Immediate deferral to spiritual care is not a substitute for engaging with the patient. The nurse should attempt to foster hope, but not in a way that downplays the patient's expressed fears.)
A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? A) "Complementary therapies generally have not been approved, so patients are usually discouraged from using them." B) "Researchers have not looked at the benefits of alternative therapy for patients with HIV, so we suggest that you stay away from these therapies until there is solid research data available." C) "Many patients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks." D) "You'll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach."
C (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. Complementary therapies and medical treatment are not mutually exclusive, though some contraindications exist. Research supports the efficacy of some forms of complementary and alternative treatment.)
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? A) Advera B) Momordicacharantia C) Megestrol D) Ranitidine
C 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. Advera is a nutritional supplement that has been developed specifically for people with HIV infection and AIDS. Momordicacharantia (bitter melon) is given as an enema and is part of alternative treatment for HIV/AIDS. Ranitidine prevents ulcers.
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? A) Maximize the patient's fluid intake. B) Provide total parenteral nutrition (TPN). C) Keep the patient's bed linens free of wrinkles. D) Provide the patient with snug clothing at all times.
C Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Fluid intake should be adequate, and must be monitored, but maximizing fluid intake is not a goal. TPN is a nutritional intervention of last resort.
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? A) Static stage B) Latent stage C) Viral set point D) Window period
C 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. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though he or she is infected
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? A) Assess the patient for additional signs and symptoms of Kaposi's sarcoma. B) Review the patient's most recent viral load and CD4+ count. C) Place the patient on respiratory isolation and inform the physician. D) Perform oral suctioning to reduce the patient's risk for aspiration.
C These signs and symptoms are suggestive of tuberculosis, not Kaposi's sarcoma; prompt assessment and treatment is necessary. There is no indication of a need for oral suctioning and the patient's blood work will not reflect the onset of this opportunistic infection.
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? A) Salmonella infection B) Mycobacterium tuberculosis C) Clostridium difficile D) Pneumocystis pneumonia
D (There are a number of opportunistic infections that can infect individuals with AIDS. The most common life-threatening infection in those living with AIDS is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly carinii). Other opportunistic infections may involve Salmonella, Mycobacterium tuberculosis, and Clostridium difficile.)
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? A) Avoid high-fat meals while taking this medication. B) Limit fluid intake to 2 liters a day. C) Limit sodium intake to 2 grams per day. D) Take this medication without regard to meals.
D (Many NRTIs exist, but all of them may be safely taken without regard to meals. Protein, fluid, and sodium restrictions play no role in relation to these drugs.)
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? A) The patient is immune to HIV. B) The patient's immune system is intact. C) The patient has AIDS-related complications. D) The patient has been infected with HIV.
D (Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications.)
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? A) Attach the condom prior to erection. B) A condom may be reused with the same partner if ejaculation has not occurred. C) Use skin lotion as a lubricant if alternatives are unavailable. D) Hold the condom by the cuff upon withdrawal.
D (The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, or cold cream should not be used with condoms because they cause latex deterioration/condom breakage. The condom should be held during withdrawal so it does not come off the penis. Condoms should never be reused.)
A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient? A) Position the patient in the high Fowler's position whenever possible. B) Temporarily eliminate animal protein from the patient's diet. C) Make sure the patient eats at least two servings of raw fruit each day. D) Obtain a stool culture to identify possible pathogens
D 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. There is no need to avoid animal protein or increase the height of the patient's bed
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? A) "There is no way to know that for certain, but we do knot that your baby has a one in four chance of being born with HIV." B) "Your physician is likely the best one to ask that question." C) "If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to worry about it now." D) "It's possible that your baby could contract HIV, either before, during, or after delivery."
D Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breast-feeding. There is no evidence that the infant's risk is 25%. Deferral to the physician is not a substitute for responding appropriately to the patient's concern. Downplaying the patient's concerns is inappropriate
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? A) "There's no way to be sure you won't get HIV except to use condoms correctly." B) "Only the correct use of a female condom protects against the transmission of HIV." C) "There are new ways of protecting yourself from HIV that are being discovered every day." D) "Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV."
D Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual transmission of HIV infection. Both female and male condoms confer significant protection. New prevention techniques are not commonly discovered, though advances in treatment are constant.