Chapter 32 PrepU: Management of Patients with Immune Deficiency Disorders

When do most perinatal HIV infections occur?

After exposure during delivery

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

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 public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize what intervention?

Educational programs that focus on control and prevention

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 client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?

Enzyme-linked immunosorbent assay (ELISA)

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?

Bone marrow transplantation

When describing the effects of treatment for phagocytic cell disorders, which of the following would the nurse include as being the most successful?

Hematopoietic stem cell transplantation

A client is considering beginning sexual relations and wants to know the best way to be protected from a sexually transmitted infection and HIV. What is the best response by the nurse?

"Using a latex condom and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV."

A client taking abacavir has developed fever and rash. What is the priority nursing action?

Report to the health care provider.

Which assessment finding(s) are likely to cause noncompliance with antiretroviral treatment? Select all that apply.

Active substance abuse

A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching?

Caregiver cleans the client's anal area without wearing gloves

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

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.

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 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 who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise?

Avoid fibrous foods, lactose, fat, and caffeine.

Which blood test confirms the presence of antibodies to HIV?

Enzyme immunoassay (EIA)

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

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

Which condition is an early manifestation of HIV encephalopathy?

Headache

There are many ethical issues in the care of clients with HIV or HIV/AIDS. What is an ethical issue healthcare providers deal with when caring for clients with HIV/AIDS?

Disclosure of the client's condition

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

The nurse is reviewing the medical record of a client who is positive for human immunodeficiency virus (HIV). The nurse notes that the client is classified as HIV asymptomatic based on which CD4+ T lymphocyte count?

Greater than 500/mm3

Which of the following is the most common HIV-related malignancy?

Kaposi's sarcoma

A female 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.

Which of the following indicates that a client with HIV has developed AIDS?

Herpes simplex ulcer persisting for 2 months

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 with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?

Immunosuppressive agents

While caring for a patient with pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate?

Kaposi's sarcoma

The nurse teaches the client that reducing the viral load will have what effect?

Longer survival

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is

Malnutrition

Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?

Past substance abuse

A nurse is preparing to administer saquinavir, which is prescribed for a client who is HIV positive. What type of drug does the nurse identify saquinavir as?

Protease inhibitor (PI)

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Risk for injury

A client taking fosamprenavir reports "getting fat." What is the nurse's best action?

Teach the client about medication side effects.

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

Which of the following are antidepressants used in the treatment of AIDS? Select all that apply.

Tofranil Norpramin Prozac

The balance between the amount of HIV in the body and the immune response is the:

Viral set point

A patient had unprotected sex with an HIV-infected person and arrives in the clinic requesting HIV testing. Results determine a negative HIV antibody test and an increased viral load. What stage does the nurse determine the patient is in?

Primary infection

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.

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)

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.

A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits what behavior?

The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.

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 implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse knows which body fluid is not a means of transmission?

Urine

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?

Vascular lesions

Kaposi sarcoma (KS) is diagnosed through

biopsy

The term used to define the amount of virus in the body after the initial immune response subsides is

viral set point.

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."

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?"

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed?

"I will be sure to eat lots of fresh fruits and vegetables every day."

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 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 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.

-Flank pain -Shaking chills -Tightness in the chest

Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?

Liquids

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.

A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority?

Disturbed body image related to loss of fat in the face and arms

The nurse is preparing to administer intravenous immunoglobulin to a client with a primary immunodeficiency. This is the client's first dose. The nurse would anticipate administering another dose in approximately which time?

4 weeks

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.

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 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

What test will the nurse assess to determine the client's response to antiretroviral therapy?

Viral load

More than 50% of individuals with this disease develop pernicious anemia:

Common variable immunodeficiency (CVID)

A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed?

Pernicious anemia

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 treatment option for severe combined immune deficiency (SCID) includes

a stem cell transplant.

In a client infected with human immunodeficiency virus (HIV), CD4+ levels are measured to determine the:

extent of immune system damage.