PrepU's Ch 32: Management of Patients with Immune Deficiency Disorders

A client with common variable immunodeficiency disease (CVID) has an order for an IVIG infusion. What actions should the nurse perform before beginning the infusion? Select all that apply.

*Measure the client's height and weight. *Premedicate with acetaminophen and diphenhydramine. *Assess baseline vital signs. *Assess for history of migraine headaches.

A client is diagnosed with severe combined immunodeficiency (SCID). What would the nurse expect to integrate into the client's plan of care?

Preparation for bone marrow transplantation For a client with severe combined immunodeficiency (SCID), the nurse would include in the plan of care preparing the client for a bone transplant. Antifungal agents are used to treat chronic mucocutaneous candidiasis. Granulocyte-stimulating factors would be used to treat immunodeficiency related to phagocytic dysfunction. A thymus graft would be used to treat DiGeorge syndrome.

A nurse is developing a teaching plan for a client with an immunodeficiency. What would the nurse need to emphasize? Select all that apply.

Prophylactic medication regimens Ways to manage stress Maintenance of a well-balanced diet Teaching for clients with immunodeficiency disorders should focus on the signs and symptoms that indicate infection, prophylactic medication regimens, the need for continued therapy without interruptions, ways to manage stress, and measures to ensure optimal nutritional status.

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 They must be informed of the need for continuous monitoring for subtle changes in the client's physical health status and of the importance of seeking immediate health care if changes are detected. Nutrition is important, but infection control is the priority. Clients and families do not choose antibiotics independently. Vaccinations are often contraindicated in immunocompromised clients.

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.

Which condition is an early manifestation of HIV encephalopathy?

Headache 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 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. In women, gynecologic problems may be the focus of the chief complaint for clients who are HIV positive but not yet diagnosed. Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may also correlate with HIV infection. Based on this information, the priority nursing action is to offer information on HIV testing to the client. Although recommending abstinence or safer-sex practices, providing a prescribed topical antifungal agent to treat the client's vaginal infection, and referring to a support group may be appropriate, the priority is to determine the source of the client's symptoms.

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 Two HIV subtypes have been identified: HIV-1 and HIV-2. HIV-1 mutates easily and frequently, producing multiple substrains that are identified by letters from A through O. HIV-2 is less transmittable, and the interval between initial infection with HIV-2 and development of AIDS is longer. HIV-1 is more prevalent in the United States and in the rest of the world. Western Africa is the primary site of infection with HIV-2. There is no cure for HIV/AIDS; hence, no cure rate. The virus is thought to be a mutation of a simian virus. Transmission of the virus is not a characteristic.

When do most perinatal HIV infections occur?

After exposure during delivery 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.

Which is usually the most important consideration in the decision to initiate antiretroviral therapy?

CD4+ counts The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts.

A client is to self-administer intravenous immunoglobulin (IVIG) in the home. What is the client's first action?

Check the IV device patency When administering intravenous immunoglobulin in the home, it is imperative to ensure that the IV access device is patent. This should be done first because if the device is not patent, it would be useless to prepare the solution, administer the premedication, or check vital signs. Unless the device is patent, the medication could not be given.

A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse closely monitor for in this client?

diarrhea and abdominal pain Common adverse effects associated with the administration of zidovudine and other NRTIs include nausea, abdominal pain and diarrhea. The drug does not cause nephropathy, decreased cognition, or pancreatitis.

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 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.

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 Despite HIV-specific confidentiality laws, clients infected with AIDS fear that disclosure of their condition will affect employment, health insurance coverage, and even housing. Since healthcare providers do not share a client's diagnosis with a support group, option A is incorrect. Caring for a client with an infectious terminal illness that can be transmitted to other people is a concern for healthcare providers but it is not an ethical issue.

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." Primary immune deficiencies should be not be confused with AIDS. They are not the same condition. In addition, a primary immune disorder does not increase the child's risk for developing AIDS later in life. Primary immune deficiency diseases are serious, but they are rarely fatal and can be controlled. Testing will reveal the evidence of a primary immune disease, not AIDS. AIDS is classified as a secondary immunodeficiency.

A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers. What severe complication should the nurse be alert for with cytomegalovirus?

blindness CMV can infect the choroid and retinal layers of the eye, leading to blindness. It does not lead to hearing impairment. Fatigue and diarrhea may occur but are not as critical as blindness.

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 parent has already reported one of the warning signs associated with primary immunodeficiencies--the use of antibiotics for 2 or more months with little effect. Another warning sign is eight or more new ear infections within 1 year. Therefore, the report of 10 ear infections in the past year would increase the nurse's suspicion. Recurrent, deep skin, or organ abscesses, failure of an infant to gain weight or grow normally, and persistent thrush (yeast infection) in the mouth or elsewhere on the skin after age 1 year would be additional warning signs. A superficial wound on the leg, age-appropriate weight, and a history of a fungal diaper rash would not be considered warning signs.

A nurse is assessing a client with Kaposi's sarcoma. What initial sign does the nurse know to look for during assessment?

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.

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. 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 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." 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 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." The majority of primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1.

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 There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.

A patient is on highly active antiretroviral therapy (HAART) for the treatment of HIV. What does the nurse know would be an adequate CD4 count to determine the effectiveness of treatment for a patient per year?

50 mm3 to 150 mm3 An adequate CD4 response for most patients on HAART is an increase in CD4 count in the range of 50 mm3 to 150 mm3 per year, generally with an accelerated response in the first 3 months.

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 Explanation: 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.

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

Active substance abuse Psychosocial barriers such as depression and other mental illnesses, neurocognitive impairment, low health literacy, low levels of social support, stressful life events, high levels of alcohol consumption and active substance use, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications affect adherence to ART. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment.

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. 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 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. 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.

A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy?

Bring the viral load to a virtually undetectable level 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?

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 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 Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions applies to very few cases of HIV infection.

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 T-cell and B-cell assays (or counts) and the enzyme-linked immunosorbent assay may be performed. A C-cell assay and plasmapheresis are distractors for this question. A complete chemistry panel is not a diagnostic test for an immune system disorder.

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 A client is classified as HIV asymptomatic when the CD4+ T lymphocyte count is greater than 500/mm3. A person is considered HIV symptomatic when the CD4+ count is 200 to 499/mm3. A person is considered to have aquired immunodeficiency syndrome (AIDS) when the CD4+ count is less than 200/mm3.

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 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.

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

Kaposi's sarcoma Kaposi's sarcoma is the most common HIV-related malignancy and involves the endothelial layer of blood and lymphatic vessels. Kaposi's sarcoma, certain types of B-cell lymphomas, and invasive cervical carcinoma are included in the CDC classification of AIDS-related malignancies.

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

Longer survival The lower the client's viral load, the longer the survival time and the longer the time to AIDS diagnosis.

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 More than 50% of clients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur.

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 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.

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

Risk for injury In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.

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 A stool specimen for ova and parasites will give a definitive diagnosis. The organism is spread by the fecal-oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude of fluid quickly leads to dehydration and electrolyte imbalances.

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. 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.

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 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.

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. Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same client. Each of the other listed actions adheres to standard precautions.

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 To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat candidiasis.

Telangiectasia is the term that refers to

Vascular lesions caused by dilated blood vessels Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia-telangiectasia is an autosomal-recessive disorder affecting both T-cell and B-cell immunity. Receptive aphasia is an inability to understand the spoken word. Dysphagia refers to difficulty swallowing.

A client with cytomegalovirus (CMV) infection reports difficulty seeing. The physician determines that the client is developing CMV retinitis. What medication does the nurse anticipate the client will receive for this?

foscarnet The drug foscarnet is used to treat CMV retinitis and is given by controlled IV infusion. Alterations in renal function, fever, nausea, anemia, numbness in the extremities, and diarrhea are the most common adverse effects. Zidovudine is used in antiretroviral therapy to prevent the conversion of HIV to AIDS. Azithromycin is an antibiotic and not used to treat CMV retinitis.

The lower the client's viral load

the longer the survival time 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.

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 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.

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

viral set point. The amount of virus in the body after the initial immune response subsides is referred to as the viral set point, which results in an equilibrium between HIV levels and the immune response that may be elicited. During the primary infection period, the window period occurs because a person is infected with HIV but negative on the HIV antibody blood test. The period from infection with HIV to the development of antibodies to HIV is known as the primary infection stage. The amount of virus in circulation and the number of infected cells equals the rate of viral clearance.

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

Common variable immunodeficiency (CVID) More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions.