CH 32: Management of Patients with immune deficiency disorder
A client is diagnosed with common variable immunodeficiency (CVID). When assessing the client for possible infection, what would the nurse identify as a least likely cause?
Pneumocystis jiroveci pneumonia Explanation: Clients with CVID are susceptible to infections with Hemophilus influenzae, streptococcus pneumoniae, and staphylococcus aureus. Opportunistic infections with Pneumocystis jiroveci pneumonia are seen only in clients with a concomitant deficiency in T-lymphocyte immunity.
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 The viral load test quantifies the plasma HIV RNA levels and response to treatment of the HIV infection. It also confirms a positive EIA result and detects HIV in high-risk seronegative individuals before antibodies are measurable.
The majority of patient with primary immunodeficiency are in which age group?
Younger than 20 Explanation: About 80% of the patients with primary immunodeficiency are younger than age 20 years.
A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client?
"Be sure to take this drug about 1/2 hour before or 2 hours after you eat." Explanation: Didanosine (Videx) should be taken 30 to 60 minutes before or 2 hours after meals. Other antiretroviral agents, such as abacavir, emtricitabine, or lamivudine can be taken without regard to meals. High-fat meals should be avoided when taking amprenavir. Atazanavir should be taken with food and not with antacids. ACQUIRED IMMUNE DEFICIENCY, TABLE 32-4 Select Antiretroviral Agents, p. 1018.
A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?
"I can eat whatever I want as long as it's low in fat." Explanation: The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client. ACQUIRED IMMUNE DEFICIENCY, Chart 32-10, p. 1027.
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." Explanation: A fungal infection, Cryptococcus neoformans is another common opportunistic infection among clients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures.
When a nurse infuses gamma globulin intravenously, the rate should not exceed
3 mL/min
The development of a positive HIV antibody test following initial infection generally occurs in which timeframe?
4 weeks Rational: Development of a positive HIV antibody test generally occurs within 4 weeks and with few exceptions by 6 months. ACQUIRED IMMUNE DEFICIENCY, HIV Infection and AIDS, p. 1015.
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 Rational: Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels. ACQUIRED IMMUNE DEFICIENCY, HIV Infection and AIDS, p. 1016.
When do most perinatal HIV infections occur?
After exposure during delivery Rational: Mother-to-child transmission of HIV-1 may occur in utero or through breastfeeding, but most perinatal infections are thought to occur after exposure during delivery. HIV Transmission, p. 1009.
A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?
AIDS Explanation: AIDS, the most common secondary disorder, is perhaps the best-known secondary immunodeficiency disorder. It results from infection with the human immunodeficiency virus (HIV). DAF refers to lysis of erythrocytes due to lack of decay-accelerating factor (DAF) on erythrocytes. CVID is a disorder that encompasses various defects ranging from IgA deficiency (in which only the plasma cells that produce IgA are absent) to severe hypogammaglobulinemia (in which there is a general lack of immunoglobulins in the blood). Severe combined immunodeficiency disease (SCID) is a disorder in which both B and T cells are missing. Page 1007
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 Explanation: Once HIV enters the host cell, attachment occurs in which the glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors. This is followed by uncoating, in which HIV's viral core is emptied into the CD4+ T cell. Cleavage and budding occur as the last steps. ACQUIRED IMMUNE DEFICIENCY, HIV Infection and AIDS, p. 1013. Chapter 32: Management of Patients with Immune Deficiency Disorders - Page 1013
When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following?
Antibodies to HIV are not present in his blood. Explanation: A negative test result indicates that antibodies to HIV are not present in the blood at the time the blood sample for the test is drawn. A negative test result should be interpreted as demonstrating that if infected, the body has not produced antibodies (which take from 3 weeks to 6 months or longer). Therefore, subsequent testing of an at-risk patient must be encouraged. The test result does not mean that the patient is immune to the virus, nor does it mean that the patient is not infected. It just means that the body may not have produced antibodies yet. When antibodies to HIV are detected in the blood, the test is interpreted as positive. ACQUIRED IMMUNE DEFICIENCY, Chart 32-7 HIV Test Results: Implications for Patients, p. 1015.
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. Explanation: A client 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 client's room. This confers more protection than disinfecting the radiology department or using masks. Chapter 32: Management of Patients with Immune Deficiency Disorders.
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. Explanation: The nurse should include interventions such as assisting with and/or performing chest physiotherapy every 2 to 4 hours to prevent stasis of secretions, assist the client to attain the semi- or high Fowler's position to facilitate breathing and airway clearance, allow for frequent rest periods to prevent excessive fatigue, and maintain a fluid intake of at least 3 liters per day unless contraindicated. Page 1028
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?
Bank autologous blood. Rational: Banking autologous blood that is self-donated is the safest option for the client. Signing the refusal form does not give the client any information about the options that are available and places the client at risk. Directed donor blood may be no safer than blood collected from public donors. Those who support this belief say that directed donors may not reveal their high-risk behaviors that put the potential recipient at risk for blood-borne pathogens such as HIV. Chapter 32: Management of Patients with Immune Deficiency Disorders.
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. Rational: Instruct the client about signs and symptoms of and the increased risk for infection. Instruct the client to report signs and symptoms of infection immediately to the physician. Early treatment promotes a shorter duration of illness and reduced complication. Tell the client to avoid high-risk activities, such as being in crowds, during periods of immunosuppression. The client should not omit a dose if nausea is experienced; he may take the medication with food. There are many side effects and required laboratory work to detect the side effects from immunosuppressive therapy. Joint aches are vague symptoms and are not a priority for reporting purposes. Chapter 32: Management of Patients with Immune Deficiency Disorders - Page 1027
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. Rational: Instruct the client about signs and symptoms of and the increased risk for infection. Instruct the client to report signs and symptoms of infection immediately to the physician. Early treatment promotes a shorter duration of illness and reduced complication. Tell the client to avoid high-risk activities, such as being in crowds, during periods of immunosuppression. The client should not omit a dose if nausea is experienced; he may take the medication with food. There are many side effects and required laboratory work to detect the side effects from immunosuppressive therapy. Joint aches are vague symptoms and are not a priority for reporting purposes. ACQUIRED IMMUNE DEFICIENCY, Chart 32-10, p. 1027.
Which is usually the most important consideration in the decision to initiate antiretroviral therapy?
CD4+ counts Explanation: The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts. HIV Infection and AIDS, Medical Management, p. 1024.
Which is usually the most important consideration in the decision to initiate antiretroviral therapy?
CD4+ counts Explanation: The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts. Chapter 32: Management of Patients with Immune Deficiency Disorders - Page 1024
The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the client?
Can you tell me what concerns you most about dying?" Rational: The nurse can help the client verbalize feelings and identify resources for support. The nurse should respond with an open-ended question to help the client 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 client's expressed fears. ACQUIRED IMMUNE DEFICIENCY, The Patient with HIV Infection, p. 1032. Chapter 32: Management of Patients with Immune Deficiency Disorders - Page 1032
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. Explanation: Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of AIDS can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.
More than 50% of individuals with this disease develop pernicious anemia:
Common variable immunodeficiency (CVID) Explanation: More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions. Page 1006
Which of the following indicates that a client with HIV has developed AIDS?
Herpes simplex ulcer persisting for 2 months Explanation: A diagnosis of AIDS cannot be made until the person with HIV meets case criteria established by the Centers for Disease Control and Prevention. The immune system becomes compromised. The CD4 T-cell count drops below 200 cells and develops one of the opportunistic diseases, such as Pneumocystis carinii pneumonia, candidiasis, cytomegalovirus, or herpes simplex. ACQUIRED IMMUNE DEFICIENCY, HIV Infection and AIDS, p. 1024.
A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?
Delayed hypersensitivity response Rational: A delayed hypersensitivity response may develop over several hours or days, or it may reach maximum severity after repeated exposure. Examples of a delayed hypersensitivity response include a blood transfusion reaction that occurs days to weeks after blood administration, rejection of transplanted tissues, and reaction to a tuberculin skin test. Anaphylaxis is a rapid and profound type I hypersensitivity response. Sensitization is the process by which cellular and chemical events occur after a second or subsequent exposure to an allergen. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly. Chapter 32: Management of Patients with Immune Deficiency Disorders.
When administering a gamma-globulin infusion, what nursing guideline applies?
Do not exceed an infusion rate of 3 mL/min. Explanation: Nursing guidelines that apply when administering IV gamma globulin include the IV infusion rate should not exceed 3 mL/min, the client should be weighed prior to treatment, clients with low gamma globulin have more severe reactions, and the nurse should administer pretreatment prophylactic antihistamine 30 minutes prior to beginning infusion.
A client asks a nurse, "What can I use to decrease my risk of exposure to HIV?" What will the nurse include as effective in reducing the risk of HIV exposure? Select all that apply.
Explanation: Based on the evidence, abstinence is the most effective means of reducing the risk of HIV transmission. Additionally, consistent and current use of latex male condoms or polyurethane female condoms are effective in decreasing the risk of HIV transmission. Lambskin condoms do not protect against HIV infection. Dental dams should be used to reduce the risk of HIV exposure during oral contact with the vagina or rectum. Chapter 32: Management of Patients with Immune Deficiency Disorders - Page 1010-1011
A patient in the clinic states, "My boyfriend told me he went to the clinic and was treated for gonorrhea." While testing for the sexually transmitted infection (STI), what else should be done for this patient?
Inform the patient that it would be beneficial to test for HIV. Explanation: HIV screening is recommended for all persons who seek evaluation and treatment for STIs. HIV testing must be voluntary and free of coercion. Patients must not be tested without their knowledge. HIV screening after notifying the patient that an HIV test will be performed (unless the patient declines) is recommended in all health care settings. Specific signed consent for HIV testing should not be required. In most settings, general informed consent for medical care is considered sufficient.
A patient in the clinic states, "My boyfriend told me he went to the clinic and was treated for gonorrhea." While testing for the sexually transmitted infection (STI), what else should be done for this patient?
Inform the patient that it would be beneficial to test for HIV. Rational: HIV screening is recommended for all persons who seek evaluation and treatment for STIs. HIV testing must be voluntary and free of coercion. Patients must not be tested without their knowledge. HIV screening after notifying the patient that an HIV test will be performed (unless the patient declines) is recommended in all health care settings. Specific signed consent for HIV testing should not be required. In most settings, general informed consent for medical care is considered sufficient. ACQUIRED IMMUNE DEFICIENCY, HIV Infection and AIDS, p. 1015.
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?
Liquids Explanation: The nurse should encourage clients with AIDS to consume liquids in order to help replace fluid and electrolyte losses. Gluten and sucrose may increase the complication of malabsorption. Large doses of iron and zinc should be avoided because they can impair immune function. NURSING PROCESS, Chart 32-10, p. 1031.
HIV is harbored within which type of cell?
Lymphocyte Explanation: Because HIV is harbored within lymphocytes, a type of white blood cell, any exposure to infected blood results in significant risk of infection. HIV infection is not harbored in platelets, erythrocytes, or nerve cells.
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is
Malnutrition Explanation: HIV Infection and AIDS, p. 1025.
Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?
Past substance abuse Explanation: Factors associated with nonadherence include active substance abuse, depression, and lack of social support, as well as neurocognitive impairment, low health literacy, stressful life events, high levels of alcohol consumption, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment. HIV Infection and AIDS, Chart 32-8, p. 1017.
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 Rational: Pneumocystic pneumonia (PCP) is one of the first and most common opportunistic infections associated with AIDS. It may be present despite the absence of crackles. If untreated, PCP progresses to cause significant pulmonary impairment and respiratory failure. ACQUIRED IMMUNE DEFICIENCY, HIV Infection and AIDS, p. 1021.
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
Rational: Adverse reactions can include reports of flank and back pain, shaking chills, dyspnea, and tightness in the chest, as well as headache, fever, and local reaction at the infusion site.
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. Rational: 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 provider would require an unacceptable delay.
The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about their medications. What is essential for the nurse to include in the teaching of this client regarding medications?
Side effects of drug therapy Rational: Describing the side effects of drug therapy is essential, with the admonition to refrain from discontinuing any of the prescribed drugs without first consulting the prescribing physician. Although the client may want to know how the drugs work in general, the specific action of each antiretroviral drug is not essential information. Teaching about condoms and vaccinations may be appropriate, but these topics are not directly related to the client's HIV medications. ACQUIRED IMMUNE DEFICIENCY, Chart 32-10, p. 1031.
Kaposi sarcoma (KS) is diagnosed through
biopsy Rational: KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count. Kaposi Sarcoma, p. 1022.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
bone marrow transplantation Rational: Treatment options for SCID include stem cell and bone marrow transplantation.
A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate?
candidiasis Rational: ACQUIRED IMMUNE DEFICIENCY, HIV Infection and AIDS, p. 1022.
A nurse is caring for a client who is HIV positive and is taking zidovudine. Which side effects should the nurse expect in this client?
diarrhea and abdominal pain Explanation: ACQUIRED IMMUNE DEFICIENCY, TABLE 32-4 Select Antiretroviral Agents (continued), p. 1019. Chapter 32: Management of Patients with Immune Deficiency Disorders - Page 1019
A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find?
hypokalemia Rational: Electrolyte imbalances such as decreased sodium, potassium, calcium, magnesium, and chloride typically result from profuse diarrhea. A urine specific gravity of 1.010 would indicate dilute urine. The client with severe diarrhea most likely would be dehydrated, leading to a high urine specific gravity. Proteinuria may suggest renal dysfunction and would not be associated with severe diarrhea unless the client was developing renal failure. ACQUIRED IMMUNE DEFICIENCY, Chart 32-10, p. 1031.
What does the nurse understand will result if the patient has a deficiency in the normal level of complement?
increased susceptibility to infection Explanation: The complement system is an integral part of the immune system, and deficiencies in normal levels of complement result in increased susceptibility to infectious diseases and immune-mediated disorders. 2022, Chapter 32: Management of Patients with Immune Deficiency Disorders.
The lower the client's viral load
the longer the survival time. Explanation: The lower the client's viral load, the longer the time to AIDS diagnosis and the longer the survival time. The key goal of antiretroviral therapy is to achieve and maintain durable viral suppression.
