Ch. 32
The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care?
Assist with chest physiotherapy every 2 to 4 hours.
Which of the following tests determines initiation of antiretroviral treatment?
CD4/CD8 ratio
Phagocytic dysfunction is characterized by the following. Choose all that apply.
Chronic eczematoid dermatitis Increased incidence of bacterial infections
A client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). The client undergoes biopsies of facial lesions and the preliminary report indicates Kaposi's sarcoma. Which action by the nurse is most appropriate?
Explore the client's feelings about facial disfigurement.
The nurse is gathering data from laboratory studies for a client who has HIV. The client's CD4+ cell count is 200/mm³, and the client has been diagnosed with pneumocystis pneumonia. What does this indicate to the nurse?
The client has converted from HIV infection to AIDS.
A client diagnosed with human immunodeficiency virus (HIV) asks how the health care provider determines what their viral load is. What is the nurse's best response?
The health care provider can have a polymerase chain reaction test run.
Which is a major manifestation of Wiskott-Aldrich syndrome?
Thrombocytopenia
A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately?
Tickle in the throat
A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which symptoms? Select all that apply.
Tightness in the chest Shaking chills Flank pain
A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?
Trimethoprim-sulfamethoxazole
The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what?
Vascular lesions caused by dilated blood vessels
Which term defines the balance between the amount of HIV in the body and the immune response?
Viral set point
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:
Western blot test for confirmation of diagnosis.
A hospital client 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?
Arrange for a portable x-ray machine to be used.
What intervention is a priority when treating a client with HIV/AIDS?
Assessing fluid and electrolyte balance
The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is:
Chronic diarrhea.
A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection?
Follow the same sexual precautions as someone who has been diagnosed with AIDS.
The nurse is preparing a teaching plan for a client with an immunodeficiency. What aspect would the nurse emphasize as most important?
Frequent and thorough handwashing
Which of the following indicates that a client with HIV has developed AIDS?
Herpes simplex ulcer persisting for 2 months
Which term means a lack of one or more of the five immunoglobulins?
Hypogammaglobulinemia
A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find?
Hypokalemia
Which substance may be used to lubricate a condom?
K-Y jelly
A nurse is preparing an in-service presentation about primary immunodeficiencies. When describing these conditions, what would the nurse need to integrate into the presentation?
Most cases are typically diagnosed in infancy.
A client is receiving ganciclovir as part of the treatment for cytomegalovirus retinitis. What would the nurse monitor the results of the client's laboratory tests for?
Neutropenia
A client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." Which nursing action is the priority for this client?
Offer information on human immunodeficiency virus (HIV) testing.
A nurse knows that more than 50% of clients with CVID develop the following disorder.
Pernicious anemia
The nurse is caring for a client who has been admitted for the treatment of AIDS. In the morning, the client tells the nurse that he experienced night sweats and recently "coughed up some blood." What is the nurse's most appropriate action?
Place the client on respiratory isolation and inform the physician.
A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect?
Pneumocystis jiroveci
The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurrence) in persons with AIDS?
Pneumocystis pneumonia
The nurse administers an injection to a client with AIDS. When finished, the nurse attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse?
Report the incident to the supervisor.
A hospital nurse has experienced percutaneous exposure to an HIV-positive client's blood because of a needlestick injury. The nurse has informed the supervisor and identified the client. What action should the nurse take next?
Report to the emergency department or employee health department.
A client at the walk-in clinic reports exposure to human immunodeficiency virus (HIV). The client wants to know the precise sources through which the HIV infection is transmitted. What is the nurse's best response?
Semen
A client 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?
Teach the client guided imagery and relaxation techniques.
A parent brings a young child to the clinic for an evaluation of an infection. The parent states, "my child has been taking antibiotics now for more than 2 months and still doesn't seem any better." During the history and physical examination, what would alert the nurse to suspect a primary immunodeficiency?
Ten ear infections in the past year
A client on antiretroviral drug therapy informs the nurse about sometimes forgetting to take the medication for a few days. What should the nurse inform the client can occur when the medications are not taken as prescribed?
The funding for the medications will cease if the client is not taking the meds correctly.
A nurse has created a plan of care for an immunodeficient client, specifying that care providers take the client's pulse and respiratory rate for a full minute. What is the rationale for this aspect of care?
These clients' blunted inflammatory responses can cause subtle changes in status.
The nurse reviews laboratory results requested to track HIV. What laboratory test measures HIV RNA levels and is the best predictor of HIV disease progression?
Viral load
A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers. What severe complication should the nurse be alert for with cytomegalovirus?
blindness
Based on the nurse's base knowledge of primary immunodeficiencies, how would the nurse complete this statement? Primary immunodeficiencies
develop early in life after protection from maternal antibodies decreases.
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply.
semen breast milk blood vaginal secretions
The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?
"The client may have cryptococcal meningitis and will need to be evaluated by the health care provider."
A nurse is teaching the parents of an infant about primary immunodeficiencies. Which statement verifies that the parents understand the teaching?
"The majority of primary immunodeficiencies are diagnosed in infancy."
A client who has been exposed to the human immunodeficiency virus (HIV) tests negative. Which explanation by the nurse would be most appropriate?
"Your body may not have developed antibodies yet, so we need to follow up."
There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency.
"Your immune system was most likely affected by an underlying disease process."
A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate?
"Although AIDS is an immune deficiency, your child's condition is different from AIDS."
Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?
Depression, memory impairment, and coma
Which blood test confirms the presence of antibodies to HIV?
Enzyme immunoassay (EIA)
A client is suspected of having an immune system disorder. The health care provider wants to perform a diagnostic test to confirm the diagnosis. What test should the nurse prepare the client for?
Enzyme-linked immunosorbent assay
A home health nurse will soon begin administering IVIG to a new client on a regular basis. What teaching should the nurse provide to the client?
Expected benefits and outcomes of the treatment
When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic?
HIV-1 is more prevalent than HIV-2 subtypes
A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen?
IV gamma globulin administration
A client is diagnosed with severe combined immunodeficiency (SCID). What would the nurse expect to integrate into the client's plan of care?
Preparation for bone marrow transplantation
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material?
Ribonucleic acid (RNA)
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family?
The need to report any slight changes in the client's health status
A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?
Use volume expanders in case blood is needed.
Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?
Vascular lesions
What test will the nurse assess to determine the client's response to antiretroviral therapy?
Viral load
The majority of patient with primary immunodeficiency are in which age group?
Younger than 20
A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid:
alcohol
Kaposi sarcoma (KS) is diagnosed through
biopsy.
The nurse is preparing to infuse gamma-globulin intravenously (IV). When administering this drug, the nurse knows the speed of the infusion should not exceed what rate?
3 mL/min
A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time?
6 weeks
A client with AIDS has become forgetful with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?
AIDS dementia complex (ADC)
A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action?
Assess blood urea nitrogen and creatinine.
A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses, including the steps in the process of HIV entering the host cell. What would the nurse describe as the first step?
Attachment
A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included?
Be alert for signs and symptoms of infection and report them immediately to the physician.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation
A client with acquired immune deficiency syndrome (AIDS) is brought to the clinic by a family member. The family member tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?
Candidiasis
A nurse is monitoring the client's progression of human immunodeficiency virus (HIV). What debilitating gastrointestinal condition found in up to 90% of all AIDS clients should the nurse be aware of?
Chronic diarrhea