Chapter 36: Management of Patients With Immune Deficiency Disorders
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
A client is diagnosed with severe combined immunodficiency (SCID). What would the nurse expect to integrate into the client's plan of care?
Preparation for bone marrow transplantation
A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of
pulmonary edema Explanation: Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would be apparent at the time of admission and would not develop after several hours. Reference:
A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful?
Brachial
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
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 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."
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 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.
Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?
Past substance abuse
A nurse knows that more than 50% of clients with CVID develop the following disorder.
Pernicious anemia
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 Explanation: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection, or stage 1. Initially, there is a period during which those who are HIV positive test negative on the HIV antibody blood test, although they are infected and highly infectious, because their viral loads are very high.
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."
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 nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?
Supporting the client's emotional status
A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?
The client agrees to detoxification, rehabilitation, and participation in an aftercare program.
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-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. Explanation: AIDS is the end stage of HIV infection. Certain events establish the conversion of HIV infection to AIDS: a markedly decreased T4 cell count from a normal level of 800 to 200/mm3 and the development of certain cancers and opportunistic infections. The client does not have advanced HIV; they meet the criteria for the development of AIDS. The T4-cell count is not decreasing due to an infection.
A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse demonstrates a need for a review of transmission routes by identifying which body fluid as a means of transmission?
Urine
Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?
Vascular lesions
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
A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client take for the treatment of this infection?
trimethoprim-sulfamethoxazole
The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed?
"I can take my child to the beach, as long as we play in the sand rather than swim in the water."
After teaching a client with immunodeficiency about ways to prevent infection, the nurse determines that teaching was successful when the client makes which statement?
"I should avoid being around other people who have an infection."
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 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
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?
Apply firm pressure over the involved area or artery.
A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action?
Assess blood urea nitrogen and creatinine.
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
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 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)
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?
Liquids
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 containing the genetic viral material?
Ribonucleic acid (RNA)
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?
Stool specimen for ova and parasites
Thirty minutes after the nurse begins an intravenous immunoglobulin (IVIG) infusion, the client reports itching at the site and a lump in the throat. Which action should the nurse take first?
Stop the infusion.
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 Explanation: Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction.
What test will the nurse assess to determine the client's response to antiretroviral therapy?
Viral load
A client with suspected human immunodeficiency virus (HIV) has had two positive enzyme-linked immunosorbent assay (ELISA) tests. What diagnostic test would be run next?
Western Blot
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.
The nurse has four clients that come to the clinic for healthcare. Which client has the highest risk factor for HIV infection?
a 26-year-old inmate who receives tattoos in prison
Kaposi sarcoma (KS) is diagnosed through
biopsy
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 majority of patient with primary immunodeficiency are in which age group?
Younger than 20
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
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is
Malnutrition
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?
Document the client's condition and absence of friends or family for obtaining consent to treatment.
A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?
Liver
A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?
Western blot assay
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."
Which is usually the most important consideration in the decision to initiate antiretroviral therapy?
CD4+ counts
A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following?
Diving in an ocean
A woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV?
Gynecologic problems
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
Which of the following indicates that a client with HIV has developed AIDS?
Herpes simplex ulcer persisting for 2 months
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?
Immunosuppressive agents
Which solution should the nurse use to replace lost fluids in a client with signs and symptoms of shock due to hemorrhaging?
Lactated Ringer solution
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