Chapter 32

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

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."

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."

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

Liquids

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.

A client with HIV will be started on a medication regimen of three medications. What class of drugs will the nurse instruct the client about?

Reverse transcriptase inhibitors

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 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.

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 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

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)

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

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.

What does the nurse understand will result if the patient has a deficiency in the normal level of complement?

Increased susceptibility to infection

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.

A nurse knows that more than 50% of clients with CVID develop the following disorder.

Pernicious anemia

A nurse is reviewing treatment options with parents of an infant born with severe combined immunodeficiency disease (SCID). The nurse recognizes that the parents understand the teaching based on which statement?

"We could have our 10-year-old daughter tested, as the ideal stem cell donor is a human leukocyte antigen-identical sibling."

A client is to receive intravenous immunoglobulin (IVIG). The infusion is started at 10 a.m. The nurse would be alert for signs and symptoms of an anaphylactic reaction during which time frame?

10:30 to 11:00 a.m.

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.

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.

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

Bone marrow transplantation

Which blood test confirms the presence of antibodies to HIV?

Enzyme immunoassay (EIA)

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 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 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

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?

Respiratory or urinary system infections

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

The lower the client's viral load,

The lower the client's viral load,

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 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.

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

A client who is HIV positive has been prescribed antiretroviral drugs. The nurse explains the action of each antiretroviral drug and develops a schedule for the client's self-administration, including strong emphasis about rigidly adhering to the dosage, time and frequency of the administration of the drugs. Why is it important to adhere to the schedule of drug dosing developed for this client?

To avoid resistance to the drugs

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.

Which substance may be used to lubricate a condom?

K-Y jelly

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid:

alcohol

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.

breast milk blood vaginal secretions semen