Med Surg: HIV and TB
Nursing Process: Plan of Care The nurse creates a plan of care for client. Education is needed on both TB, HIV, along with medications. The nurse outlines interventions in the plan of care. Which statements by client indicates that they understands why they are at risk for TB? (Select all that apply. One, some, or all options may be correct.) Select all that apply - "I realize my helper T cells are diminished from HIV. Those are the cells needed to fight TB." - "I may get TB because my viral load count is diminished." - "I am at risk for developing TB because I was born with a low number of helper T cells." - "I realize I am at risk for acquiring TB because I used intravenous drugs in the past." - "I guess living in that homeless shelter increased my chances of getting TB."
"I realize my helper T cells are diminished from HIV. Those are the cells needed to fight TB." HIV attacks the CD4 receptors on the helper T cells that help the body fight off diseases such as TB. "I guess living in that homeless shelter increased my chances of getting TB." The risks of acquiring the infection and of developing clinical disease depends on the infections existence in the population, especially among persons residing in high-risk environments for the transmission of TB, such as correctional facilities, homeless shelters, hospitals, and nursing homes.
How should the nursing supervisor respond to the staff PN who does not want to care for client? - "I understand. I will assign you to a different client and give client to one of the other PNs." - "I understand you are concerned, but I am concerned about you losing your job over this." - "I understand your fears, but do you realize this will cause a hardship on your fellow staff members?" - "I understand you want to protect your children. Please tell me your concerns regarding caring for a client with HIV."
"I understand you want to protect your children. Please tell me your concerns regarding caring for a client with HIV." This response by the nurse supervisor demonstrates compassion and provides an opportunity to discover if education of the staff PN is needed.
Nursing Process: Evaluation Before client is discharged home, it is important that they understands how to prevent the spread of HIV. When discussing infection control practices with the nurse the client says that they have heard that condoms don't always prevent HIV. How should the nurse respond? - "If used correctly and consistently, latex condoms are highly effective in preventing the transmission of HIV." - "I know you would feel terrible if you passed HIV to someone because you did not use a condom." - "I will have an AIDS educator discuss condom use with you." - "What is your source of information about condom failure?" Submit
"If used correctly and consistently, latex condoms are highly effective in preventing the transmission of HIV." Client's misinformation and misunderstanding is a common myth regarding the effectiveness of latex condoms. Studies prove that condoms work.
After 3 days, the nurse receives the results from client's tuberculin skin test that was administered at his HCP's office. Even though client's reaction to the tuberculin skin test measures only 5 mm in diameter, the HCP documents a positive test result. A new graduate nurse finds this confusing. The new graduate nurse thought that a 10 mm induration was the minimum size for a positive reading and asks the nurse preceptor for clarification. How should the nurse preceptor respond? - "This confuses me, too. I think we need to consult with the HCP." - "That is not always true. A 5 mm induration is considered positive for TB in a person with HIV." - "It may be that you are confusing induration with inflammation in skin testing results." - "Let's ask the nurse practitioner who specializes in caring for clients who are HIV positive."
"That is not always true. A 5 mm induration is considered positive for TB in a person with HIV." The person with HIV has diminished T cell immunity, which compromises their ability to react to skin tests. Therefore, an induration of 5 mm is considered a positive reaction, rather than the standard of 10 to 15 mm for other groups.
Client responds by agreeing to take their medications as prescribed and states they don't really know how good they will do. How should the nurse respond? - "I honestly do not know, but I would give it a try. What is there to lose?" - "The main purpose of these medicines is to block the replication of the HIV virus." - "You should talk to your HCP about your medications." - "Tell me about the experiences your friends have had with these medicines."
"The main purpose of these medicines is to block the replication of the HIV virus." The purpose of the antiretroviral and inhibitor medicines is to block the replication of the HIV virus and prevent opportunistic diseases.
Client is admitted from his healthcare provider's office (HCP) to the acute care facility. He was diagnosed HIV positive 2 years ago. His history includes fatigue, a productive cough, and weight loss. A tuberculosis (TB) skin test was administered in the HCP's office. Admission orders include "isolation precautions for suspected pulmonary tuberculosis." Nursing Process: Assessment The nurse admits client to a private room at the end of the hall. According to hospital protocol, the nurse puts on a mask before starting the admission process. Client tells the nurse that their significant other is downstairs and that they would like for them to stay in the room with them. How should the nurse respond? - "Your healthcare provider (HCP) wants you to get some rest." - "Your significant other may stay, but only after we have the results of their tuberculin skin test." - "They may stay, but they need to wear a mask." - "You don't want to risk infecting your significant other with TB, do you?"
"They may stay, but they need to wear a mask." Client's significant other may stay in the room, but they should wear a mask to help decrease the possibility of contracting the TB organism.
Pharmacologic and Parenteral Therapies Before breakfast, the nurse brings client the HIV medicines that are due. Client inquires about their other medications, stating that they take all of their HIV pills at once before breakfast and does not want to bother with taking medications all day long. How should the nurse reply? - "To be most effective, HIV medications are prescribed on different schedules." - "Okay. I will give the rest to the UAP to bring in as soon as possible." - "We are just trying to provide you with the best nursing care possible on this unit." - "We need your cooperation to help fight this disease."
"To be most effective, HIV medications are prescribed on different schedules." Some HIV inhibitors need to be given on an empty stomach and some need to be given with food for best effectiveness. Many need to be taken around the clock, even if sleep is disrupted, to ensure drug efficacy.
Client's stool cultures are negative. After treatment with fluids and diet modification, their diarrhea resolves in 24 hours. Fluid balance is restored, and their oral candidiasis is resolving. The HCP is notified of client's physical exam findings indicating possible dehydration and vital signs, including a blood pressure of 100/50. It is determined that client could use a bolus of IV fluids. The HCP prescribes 1000 mL of sodium chloride 0.45% to run over 6 hours. The drop factor tubing set is 15 drops (gtts)/mL. How many drops (gtts)/minute will the IV run? (Enter the numeric value only. If rounding is required, round to the whole number.)
42
The nurse notices the UAP about to enter client's room to deliver a meal tray without wearing any protective apparel. What information should the nurse provide to the UAP? - A fit-tested HEPA mask is required for healthcare workers entering the room of someone suspected of having active TB. - Wearing a mask, gown, and gloves is required for healthcare workers entering client's room for any reason. - The UAP will only be in the room for a brief moment to deliver the tray, so no intervention is needed by the nurse. - Non-sterile gloves are necessary to deliver the meal and prevent the spread of TB.
A fit-tested HEPA mask is required for healthcare workers entering the room of someone suspected of having active TB. TB is spread by airborne transmission of droplet nuclei. A specific fit tested, high-efficiency particulate air (HEPA) mask is necessary to filter the mycobacterium tuberculosis bacillus.
Client assures the nurse that they will use a condom with each sexual encounter. The client also expresses concern that they may become dehydrated again. What resource can be provided for client in the event this complication occurs? - Meals on Wheels. - HIV/AIDS support group. - Access to the services of a registered dietitian. - Access to a nurse on hospital unit.
Access to the services of a registered dietitian. It is essential that the nurse arrange a consult for client with a registered dietitian before they are discharged home. The dietitian will give specific information on suggested foods and liquids to include in their diet to help prevent dehydration if diarrhea occurs at home. The registered dietitian will provide client with resources, such as a phone number, that will give them access to the dietitian on an outpatient basis.
Client's significant other arrives. Client wants to know why a mask is necessary for people entering their room. What teaching should the nurse implement? - Explain the use of a private room and mobile high-efficiency particle filters placed in the room. - Explain that the tuberculosis (TB) organism is most often spread through the air. - Tell client that tuberculosis (TB) will not be spread to others, and everything will be okay if the mask is worn. - Tell client that masks are required for those persons who do not agree to be vaccinated with BCG vaccine.
Explain that the tuberculosis (TB) organism is most often spread through the air. When an infected person coughs or sneezes, they produce infectious droplets that can be breathed in by another person. This answer provides client with the scientific rationale for wearing a mask.
When performing client's morning physical assessment, the nurse discovers that the client has a weak, rapid pulse, decreased skin turgor, and dry, sticky, oral mucous membranes. The client's weight is 2 lbs (0.91 kg) less than it was yesterday morning. What is the highest priority issue for client with diarrhea? - Fatigue. - Sleep is disrupted. - Fluid volume is decreased and client develops dehydration. - Discouragement and low self-esteem.
Fluid volume is decreased and client develops dehydration. A weak, rapid pulse; decreased skin turgor; dry, sticky, oral mucous membranes; and weight loss are signs of dehydration.
Nursing Process: Planning Client has been diagnosed with the opportunistic disease TB. He has experienced weight loss and has a CD4 cell count of 240 cells/mm3 (0.24 x 109L).The HCP moves client from the HIV asymptomatic stage (CDC HIV Infection Stage 1) to the HIV Infection Stage 3 (AIDS). Safety and Infection ControlA UAP asks the nurse now that client's condition has worsened and they have been moved to the HIV symptomatic stage, should added precautions be posted on their door to protect staff members. What information should the nurse give the UAP? - Following standard precautions will minimize the exposure to blood and body fluids. - Reverse isolation procedures should be implemented to protect the staff. - Respiratory precautions are all that are needed, and those are already posted on the door. - Staff members caring for client should begin prophylaxis medications.
Following standard precautions will minimize the exposure to blood and body fluids. Standard precautions are designed to prevent contact with blood or body fluids, which are the mode of transmission for HIV, and are used regardless of the stage classification of the disease.
Nursing Process: Intervention An acid-fast bacilli (AFB) stain is part of the initial admission orders. Early morning sputum specimens will be collected for 3 consecutive days and sent to the lab. Click for Image Which tasks may the nurse delegate to the UAP? (Select all that apply. One, some, or all options may be correct.)
Have the UAP tell client that the specimen must be collected in the early morning. Provide client with three sterile specimen cups at his bedside. Document the time and date that each sputum specimen was collected. This task may be safely delegated. However, it is the nurse's responsibility to ensure that the documentation is completed and sent with the specimen to the lab.
Since client now has oral candidiasis (thrush), in addition to fatigue and anorexia, which food best contributes to improving his nutrition? - Broiled steak. - Milk shake. - Tomato soup. - Lettuce salad with raw vegetables.
Milk shake. A milk shake is a nutrient-dense food. It provides needed calories, calcium, and protein. Client can drink the nutritious snack without using the energy it would take to eat a full meal. Client may find that the cool liquid is soothing to their sore mouth.
Client is scheduled for several activities the following morning. Which activity should client perform first upon awakening? - Eat a nutritionally dense, early morning snack sent from the food services department. - Obtain the first of three sputum specimens for laboratory testing. - Take a shower and get ready to go to radiology for a chest X-ray. - Weigh to determine if weight loss from the disease is continuing.
Obtain the first of three sputum specimens for laboratory testing. Secretions collecting during the night provide the opportunity for the client to cough and expectorate upon awakening before performing other morning activities.
The nurse notifies the HCP, who prescribes nystatin 6 mL by mouth (PO) 4 times per day. What instruction should the nurse give client about the use of liquid nystatin? - Place all of the suspension in the mouth, then swish and swallow immediately. - Sip the suspension over 5 minutes, swishing and swallowing after each sip. - Place the suspension in the mouth, then swish for several minutes before swallowing. - Use the applicator to paint the medication on the infected sites and swallow the remaining dose.
Place the suspension in the mouth, then swish for several minutes before swallowing. This "swish and swallow" technique is the proper way to take liquid nystatin. HCPs also recommend gargling, as well as swishing, prior to swallowing.
Which complication of HIV is priority for the client at this time? Potential for new opportunistic infections since HIV alters the function of the immune system. Social isolation related to worsening of condition. Nutritional deficits caused by medication side effects. Fatigue due to altered chemical balance. Submit
Potential for new opportunistic infections since HIV alters the function of the immune system. Since client's immune system is no longer competent, they are at risk for additional opportunistic infections. Immune problems start when the CD4 cell count drops below 500 cells/mm3. Preventing infections is a basic need and is a high priority in the immunocompromised client.
Nursing Process: Intervention Client is 5' 11" (180.3 cm) tall. They have a large frame and weighs 152 lbs (68.9 kg). The client's current body mass index (BMI) is 17.4. Client says that they realize they should eat, but they do not have the energy or the appetite, even when they have no oral pain. The nurse identifies that the client requires nutritional intervention and updates the plan of care. To achieve the goal of improving client's nutrition, the nurse should perform which nursing intervention? (Select all that apply. One, some, or all options may be correct.) Select all that apply - Request a dietary consultation for the client to better assess client's nutritional status and food preferences. - Request a prescription for total parenteral nutrition. - Monitor for oral candidiasis (thrush) and diarrhea. - Instruct client to focus on breakfast, the most important meal of the day. - Weigh daily and record signs of wasting syndrome.
Request a dietary consultation for the client to better assess client's nutritional status and food preferences. Determining clients food preferences is a good first step. It is essential that they be an active participant in their care so they have some control. If a favorite food is not on the menu, it can be requested. Monitor for oral candidiasis (thrush) and diarrhea. HIV can cause profuse diarrhea, night sweats and decreased appetite due to yeast.
Client's HCP has also prescribed the anti-tubercular regimen of rifabutin/isoniazid/pyrazinamide/ethambutol. What information is important to teach client about the use of rifabutin/isoniazid/pyrazinamide/ethambutol? (Select all that apply. One, some, or all options may be correct.) Select all that apply - Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange. - Liver function tests should be routinely conducted and monitored. - Sunscreen is recommended when exposed to sunlight while taking rifabutin/isoniazid/pyrazinamide. - Visual disturbances related to ethambutol therapy may develop during therapy, but may resolve once treatment is discontinued. - Rifampin/isoniazid/pyrazinamide has been known to cure HIV within a few months of taking it.
Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange. This teaching can help client prepare for this side effect without anxiety. Liver function tests should be routinely conducted and monitored. The major side effect of isoniazid, rifabutin, and pyrazinamide is drug-induced hepatitis. Therefore, client must be taught the importance of having blood samples drawn to monitor their liver function. Sunscreen is recommended when exposed to sunlight while taking rifabutin/isoniazid/pyrazinamide. Pyrazinamide may make the skin sensitive to sunlight, and this should be taught to the client.
Which action should the nurse take first? - Hold client's breakfast tray to provide bowel rest. - Perform oral care and moisten mucous membranes. - Take client's blood pressure to assess for postural hypotension. - Notify the HCP of client's weak, rapid pulse.
Take client's blood pressure to assess for postural hypotension. Postural hypotension can result from dehydration. Therefore, it is important for the nurse to obtain this vital information because it directly impacts client's safety.
Safe and Effective Care Environment: Management of Care A practical nurse (PN) says to the nurse who is making assignments that they do not want to be assigned to care for this client because they have never cared for a client with HIV and do not want to start now. The PN expresses concern for family at home that needs them. Which information should the nurse base a response about the PN's right to refuse care for a client with HIV? - The PN does not have enough experience to care for a client who is on isolation and may therefore refuse to care for clients with a contagious disease. - The PN may refuse to care for a client in circumstances in which risk to the nurse outweighs the nurse's responsibility to care for a client, or if the assignment conflicts with the nurse's ethical standards. - Refusal to treat or care for a person based on race, gender, or age is discrimination, which the federal government prohibits. - The required staffing ratio of licensed personnel to client population does not allow for professional nurses to refuse to care for a client.
The PN may refuse to care for a client in circumstances in which risk to the nurse outweighs the nurse's responsibility to care for a client, or if the assignment conflicts with the nurse's ethical standards. According to the ANA Code for Nurses, a nurse may morally refuse to participate in care, but only on the grounds of either client advocacy or moral objection to a specific type of intervention. Exceptions may be made when risk of harm outweighs the nurse's responsibility to care for a given client. For example, an immunosuppressed nurse may refuse to care for clients with certain infectious processes. The pregnant nurse may refuse to care for the client with HIV who has secondary infections such as toxoplasmosis or cytomegalovirus, both of which can cause severe damage or death to the fetus.
Safety and Infection Control The unlicensed assistive personnel (UAP) asks why client could not be in an empty semiprivate room closer to the nurse's station so the staff would not have to walk so far to provide care. What information should the nurse provide to the UAP on infection control practices? - The client needs to be at the end of the hall because he requires privacy. - The implementation of airborne precautions for possible TB requires a private, negative pressure room assignment. - A private room is required to implement contact precautions for possible TB. - The client needs to be at the end of the hall for confidentiality.
The implementation of airborne precautions for possible TB requires a private, negative pressure room assignment. According to the Centers for Disease Control (CDC), in addition to isolating client by using a private room, engineering controls can help to prevent the spread of TB. Controlling the direction of the airflow can prevent contamination of air in adjacent areas.
Risk Potential Client develops severe diarrhea with occasional incontinence that could be caused by an opportunistic gastrointestinal infection or by one of their medications. While stool cultures are pending, other interventions can be initiated. Which tasks can be delegated to the UAP? (Select all that apply. One, some, or all options may be correct.) Select all that apply - Weigh the client each morning before breakfast. - Measure the urine output. - Count and record the number of watery stools. - Assess client's peri-rectal skin during incontinent care. - Check client's skin turgor to determine if he is dehydrated.
Weigh the client each morning before breakfast. Measure the urine output. Count and record the number of watery stools. The UAP can legally count and record the number of watery stools. However, it is the nurse's responsibility to be aware of the client's condition and promptly report any significant changes to the HCP.
Reduction of Risk Potential The nurse notices that client has left most of their dinner untouched. The nurse offers to order something different, but they reply that their mouth is sore and they just don't feel like eating. Which assessment finding by the nurse would be indicative of oral candidiasis (thrush), a common secondary infection in persons with compromised immune systems? - Blisters on the tongue or oral mucosa. - Inflammation of the gums. - Painless white lesions on the lateral surface of the tongue. - White-yellow patches on the tongue or oral mucosa.
White-yellow patches on the tongue or oral mucosa. This sign is indicative of a Candida albicans (thrush) infection. It is a common finding in people with HIV, and it frequently occurs with a falling CD4 cell count.
