Adult Health Ch. 36

The nurse is obtaining an assessment and health history from the parents of a 6-month-old infant with an elevated temperature. Which statement by the parents alerts the nurse to a possible immunodeficiency disorder?

"This is the third infection with a high fever the baby has had in the past month."

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."

The nurse is instructing a male client about safer sexual behaviors. Which client statement indicates a need for additional instruction?

"I will apply baby oil to lubricate the condom."

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."

Which blood test confirms the presence of antibodies to HIV?

Enzyme immunoassay (EIA)

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

What intervention is a priority when treating a client with HIV/AIDS?

Assessing fluid and electrolyte balance

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 patient with common variable immunodeficiency (CVID) is extremely fatigued and not feeling well. What lab test does the nurse anticipate the patient will have to detect a common development related to the disease?

B12 level

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.

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

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 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 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

When a nurse infuses gamma globulin intravenously, the rate should not exceed

3 mL/min

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

Kaposi sarcoma (KS) is diagnosed through

biopsy

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." What should the nurse consult with the physician regarding?

testing the client for the presence of HIV

A nurse is assessing a client with a primary immunodeficiency. Afterward the nurse documents that the client displayed ataxia. The nurse makes this documentation because the client has

uncoordinated muscle movements.

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

viral set point.

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)

When do most perinatal HIV infections occur?

After exposure during delivery

A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action?

Assess blood urea nitrogen and creatinine.

A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses, including the steps in the process of HIV entering the host cell. What would the nurse describe as the first step?

Attachment

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

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

CD4+ counts

Which of the following is the first barrier method that can be controlled by the woman?

Female condom

A client with acquired immune deficiency syndrome (AIDS) is brought to the clinic by a family member. The family member tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?

HIV encephalopathy

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 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

Phagocytic dysfunction is characterized by the following. Choose all that apply.

Increased incidence of bacterial infections Chronic eczematoid dermatitis

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.

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

Liquids

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

Report to the health care provider.

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

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

Teach the client about medication side effects.

Which would be inaccurate information pertaining to SCID?

The inheritance of SCID can be autosomal dominant.

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

Telangiectasia is the term that refers to

Vascular lesions caused by dilated blood vessels

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.

Which type of phagocytic disorder (formerly known as Job syndrome) occurs when white blood cells cannot initiate an inflammatory response to infectious organisms?

Hyperimmunoglobulinemia E

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

A client with chronic mucocutaneous candidiasis, an autosomal recessive disorder, asks the nurse, "Will my children have this disease?" Which response by the nurse is appropriate?

"All of your children will be carriers of the recessive gene but may not develop the disease."

A client receiving atazanavir requires what priority intervention?

Cardiac assessment

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.

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

Nursing students are reviewing information about the various types of primary immunodeficiencies. The students demonstrate understanding of the material when they identify which of the following as an example of a primary immunodeficiency involving B-lymphocyte dysfunction?

CVID

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)

The nursing instructor is talking about HIV/AIDS with their pre-nursing pathophysiology class. The instructor explains to the class that the virus that causes HIV/AIDS is called a retrovirus. What characteristics of this retrovirus would the instructor talk with the class about?

HIV-1 and HIV-2 subtypes

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."

The nurse is working with a parent whose child has just been diagnosed with selective immunoglobulin A deficiency. The parent asks the nurse, "Does this mean that my child is going to die?" How should the nurse respond?

"Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract."

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

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

Viral load