medsurge test 4
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 Platelet administration Factor VIII administration Thymus grafting
Correct response: IV gamma globulin administration Explanation: Treatment for ataxia-telangiectasia includes IV gamma globulin, antimicrobial therapy, and bone marrow transplantation. It does not include platelet administration, factor VIII administration, or thymus grafting.
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? Deoxyribonucleic acid (DNA) Ribonucleic acid (RNA) Viral core Glycoprotein envelope
Correct response: Ribonucleic acid (RNA) Explanation: HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins.
A client taking fosamprenavir reports "getting fat." What is the nurse's best action? Have the client increase exercise. Assess the client's diet. Teach the client about medication side effects. Arrange for a psychological counseling.
Correct response: Teach the client about medication side effects. Explanation: The client needs to be aware of the potential for fat redistribution. Exercise, diet, and counseling will not change the outcome of this side effect.
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 Hunger Fatigue
Flank pain Shaking chills Tightness in the chest Explanation: 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.
Which of the following are common sites of visceral involvement of Kaposi's sarcoma? Select all that apply. Lymph nodes Gastrointestinal tract Lungs Brain Heart
Lymph nodes Gastrointestinal tract Lungs Explanation: The most common sites of visceral involvement are the lymph nodes, the gastrointestinal tract, and the lungs. Involvement of internal organs may eventually lead to organ failure, hemorrhage, infection, and death. The brain and the heart are not common sites.
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? If the client experiences nausea, omit the dose. If the client experiences nausea, omit the dose. The client should be alert for joint aches. This medication is commonly used for many inflammatory reactions and is relatively safe. Be alert for signs and symptoms of infection and report them immediately to the physician.
You Selected: Be alert for signs and symptoms of infection and report them immediately to the physician. Correct response: Be alert for signs and symptoms of infection and report them immediately to the physician. Explanation: 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.
Which blood test confirms the presence of antibodies to HIV? Erythrocyte sedimentation rate (ESR) p24 antigen Reverse transcriptase Enzyme immunoassay (EIA)
You Selected: Enzyme immunoassay (EIA) Correct response: Enzyme immunoassay (EIA) Explanation: EIA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.
An HIV-infected client presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL, and the nurse recognizes the client's increased risk for Mycobacterium avium complex (MAC disease). The nurse should anticipate the administration of what drug? Azithromycin Vancomycin Levofloxacin Fluconazole
Azithromycin Correct response: Azithromycin Explanation: HIV-infected adults and adolescents should receive chemoprophylaxis against disseminated Mycobacterium avium complex (MAC disease) if they have a CD4+ count less than 50 cells/µL. Azithromycin or clarithromycin are the preferred prophylactic agents. Vancomycin, levofloxacin, and fluconazole are not prophylactic agents for MAC.
A nurse works in an employee health department of a hospital. She was asked to treat a staff nurse who was exposed to blood from a patient with an HIV infection. The nurse practitioner instituted a PEP protocol that includes which of the following actions? Select all that apply. Start prophylaxis medications between 3 to 6 hours after exposure. Continue HIV medications for 4 weeks postexposure. Practice safe sex for 2 weeks (time for HIV medications to reach a satisfactory blood level). Initiate postexposure testing after 4 weeks. Finish postexposure testing at 6 months.
Continue HIV medications for 4 weeks postexposure. Initiate postexposure testing after 4 weeks. Finish postexposure testing at 6 months.
A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? "You should take the drug with an antacid." "It doesn't matter if you take this drug with or without food." "Be sure to take this drug about 1/2 hour before or 2 hours after you eat." "When you take this drug, eat a high-fat meal immediately afterwards."
Correct response: "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.
A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? "I won't go to see my sister while she has a cold." "I can eat whatever I want as long as it's low in fat." "I stopped smoking last year; this year I'll quit drinking alcohol." "I won't go to see my nephew right after he gets his vaccines."
Correct response: "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.
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. Have the client wear a mask to the x-ray department. Ensure that the radiology department has been disinfected prior to the test. Send the client to the x-ray department, and have the staff in the department wear masks.
Correct response: 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.
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? Maintain the client in a supine or side-lying position. Encourage client to ambulate frequently in the halls. Assist with chest physiotherapy every 2 to 4 hours. Limit fluid intake to 1 1/2 to 2 liters per day.
Correct response: 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.
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? Sign a refusal of blood transfusion form so the client will not receive the transfusion. Bank autologous blood. Ask people to donate blood. Use volume expanders in case blood is needed.
Correct response: Bank autologous blood. Explanation: 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.
A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy? Reverse the HIV+ status to a negative status. Treat mycobacterium avium complex. Eliminate the risk of AIDS. Bring the viral load to a virtually undetectable level
Correct response: Bring the viral load to a virtually undetectable level Explanation: The goal of antiretroviral therapy is to bring the viral load to a virtually undetectable level. This level is no more than 500 or 50 copies, depending on the sensitivity of the selected viral load test. It is not possible to reverse the status to a negative, and it cannot eliminate the risk of AIDS but can help with prolonging the asymptomatic stage of HIV. Antiretroviral therapy does not treat mycobacterium avium complex.
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? 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? Anorexia Chronic diarrhea Nausea and vomiting Oral candida
Correct response: Chronic diarrhea Explanation: Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of acquired immune deficiency syndrome (AIDS) can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.
A client seeks medical attention to learn why an infection has been resistant to antibiotic therapy. Which laboratory test will the nurse anticipate being used first to determine if the client has a primary immune deficiency disease (PIDD)? Immunoglobulin levels HIV-1 differentiation assay HIV-1/HIV-2 immunoassay Complete blood count and differential
Correct response: Complete blood count and differential Explanation: The majority of primary immune deficiency diseases (PIDDs) are rare inherited disorders that impair the immune system. Adults may present with clinical episodes of infectious diseases beyond the scope of normal immunocompetence, such as infections that are unusually persistent, recurrent, or resistant to treatment and that involve unexpected dissemination of disease or atypical pathogens. Laboratory tests are used to identify antibody deficiencies, cellular (T-cell) defects, neutrophil disorders and complement deficiencies. A complete blood cell count with manual differential should always be analyzed first. Immunoglobulin tests would be used to determine the antibody responses to vaccines. The HIV-1 differentiation assay differentiates HIV-1 from HIV-2. The HIV-1/HIV-2 immunoassay tests for both HIV-1 and HIV-2 antibodies.
A nurse is assessing a client with Kaposi's sarcoma. What initial sign does the nurse know to look for during assessment? Severe joint pain Lymphedema of the lower extremities Deep purple cutaneous lesions Venous stasis and phlebitis formation
Correct response: Deep purple cutaneous lesions Explanation: Localized cutaneous lesions may be the first manifestation of this HIV-related malignancy, which appears in 90% of clients as immune function deteriorates. Other symptoms develop over time as the lesions increase in size and spread to other locations.
Which blood test confirms the presence of antibodies to HIV? Erythrocyte sedimentation rate (ESR) p24 antigen Reverse transcriptase Enzyme-linked immunosorbent assay (ELISA)
Correct response: Enzyme-linked immunosorbent assay (ELISA) Explanation: ELISA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. The p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.
Which of the following is the first barrier method that can be controlled by the woman? Female condom IUD Diaphragm Birth control pill
Correct response: Female condom Explanation: The female condom has the distinction of being the first barrier method that can be controlled by the woman. The IUD may increase the risk for HIV transmission through an inflammatory foreign body response. The female condom is as effective in preventing pregnancy as other barrier methods, such as the diaphragm and the male condom. Birth control pills are not a barrier method.
Which condition is an early manifestation of HIV encephalopathy? Hyperreflexia Headache Vacant stare Hallucinations
Correct response: Headache Explanation: Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.
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? Test for HIV without informing the patient. Test for HIV, requiring the patient to sign a permit. Inform the patient that it would be beneficial to test for HIV. Administer treatment for the STI and discharge the patient.
Correct response: 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.
Which substance may be used to lubricate a condom? Skin lotion Baby oil K-Y jelly Petroleum jelly
Correct response: K-Y jelly Explanation: K-Y jelly is water-based and will provide lubrication while not damaging the condom. The oils in skin lotion and petroleum jelly, and baby oil, will cause a latex condom to break.
Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment? Active substance abuse Depression Past substance abuse Lack of social support
Correct response: 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 treatmen
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? Mycobacterium avium complex Legionella Cytomegalovirus Pneumocystis jiroveci
Correct response: Pneumocystis jiroveci Explanation: Although mycobacterium, legionella, and cytomegalovirus may cause the signs and symptoms described, the most common infection in people with AIDS is pneumocystis pneumonia caused by pneumocystis jiroveci. It is the most common opportunistic infection associated with AIDS.
A client with human immunodeficiency virus (HIV) develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this client? Mycobacterium avium complex (MAC) Pneumocystis pneumonia Tuberculosis Community-acquired pneumonia
Correct response: Pneumocystis pneumonia Explanation: The most common life-threatening infection in those living with acquired immune deficiency syndrome (AIDS) is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly P. carinii) (Durham & Lashley, 2010). Without prophylactic therapy, most people infected with HIV will develop PCP. The clinical presentation of PCP in HIV infection is generally less acute than in people who are immunosuppressed as a result of other conditions. Clients with HIV infection initially develop nonspecific signs and symptoms, such as nonproductive cough, fever, chills, shortness of breath, dyspnea, and occasionally chest pain. Arterial oxygen concentrations in clients who are breathing room air may be mildly decreased, indicating minimal hypoxemia.
A client taking abacavir has developed fever and rash. What is the priority nursing action? Administer acetaminophen. Document the information. Report to the health care provider. Administer lidocaine cream for the rash.
Correct response: Report to the health care provider. Explanation: Fever and a rash could be indicative of a hypersensitivity reaction. Hypersensitivity reactions are also known as anaphylactic reactions and often involve skin rashes, fever, and bronchopulmonary issues such as bronchial constriction. The health care provider should be notified immediately and the medication stopped. Interventions need to be taken to assure that the client's airway is not compromised. Administering acetaminophen and documentation and treating the rash are not the priority and would be completed after the client is stabilized.
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 Respiratory or urinary system infections Rheumatoid arthritis Cardiac dysrhythmias and heart failure
Correct response: Respiratory or urinary system infections Explanation: Secondary immunodeficiencies occur as a result of underlying disease processes or the treatment of these disorders, including administration of immunosuppressive agents. Abnormalities of the immune system affect both natural and acquired immunity. Because immunodeficiencies result in a compromised immune system and pose a high risk for infection, careful assessment of the client's immune status is essential. The nurse assesses and monitors the client for signs and symptoms of infection.
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? Anticholinergics Disinhibitors Reverse transcriptase inhibitors Hydroxyurea
Correct response: Reverse transcriptase inhibitors Explanation: Reverse transcriptase inhibitors are drugs that interfere with the virus' ability to make a genetic blueprint. A protease inhibitor is a drug that inhibits the ability of virus particles to leave the host cell. The integrase inhibitors are a class of drug that prevents the incorporation of viral DNA into the host cell's DNA. Hydroxyurea is a drug that is used as an adjunct therapy that tries to halt the progression of AIDS.
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. Give the client more control of her antiretroviral regimen. Increase the client's activity level. Collaborate with the client's physician to obtain an order for hydromorphone.
Correct response: Teach the client guided imagery. Explanation: Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue. Increased activity may be of benefit, but for other clients this may exacerbate feelings of anxiety or loss. Granting the client control has the potential to reduce anxiety, but the client is not normally given unilateral control of the ART regimen. Hydromorphone is not used to treat anxiety.
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 Nystatin Amphotericin B Fluconazole
Correct response: Trimethoprim-sulfamethoxazole Explanation: To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat candidiasis.
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. occur most commonly in the aged population. develop as a result of treatment with antineoplastic agents. disappear with age.
Correct response: develop early in life after protection from maternal antibodies decreases. Explanation: These disorders may involve one or more components of the immune system. Primary immunodeficiencies are seen primarily in infants and young children. Primary immunodeficiencies are rare disorders with genetic origins. Without treatment, infants and children with these disorders seldom survive to adulthood.
