Chapter 36

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

Report to the health care provider.

Which of the following indicates that a client with HIV has developed AIDS?

Herpes simplex ulcer persisting for 2 months

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

Viral load

A client with paroxysmal hemoglobinuria, a deficiency of complement proteins, reports headache and weakness of the right arm and leg. Based on these symptoms, for which health complication should the nurse assess?

Cerebral venous thrombosis

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 nursing student is preparing a teaching plan for a client with an immunodeficiency disorder. The student is going to include the cardinal symptoms in teaching. Which of the following would the student include? Choose all that apply.

Poor response to treatment of infections Chronic diarrhea Chronic or recurrent severe infections

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.

semen breast milk blood vaginal secretions

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 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 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?

Pneumocystis pneumonia

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

When do most perinatal HIV infections occur?

After exposure during delivery

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

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

Teach the client about medication side effects.

A client with human immunodeficiency virus undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. What accurate conclusion can the nurse make?

The client is immunodeficient and won't have a skin response.

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

Nursing management of a patient who requires immunosuppression must include use of __________ precautions when providing care to prevent infection.

standard

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 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."

Antiretroviral medications as post-exposure prophylaxis for health care workers are started within ____ hours of exposure.

72

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 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 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

Which blood test confirms the presence of antibodies to HIV?

Enzyme immunoassay (EIA)

Which blood test confirms the presence of antibodies to HIV?

Enzyme-linked immunosorbent assay (ELISA)

T or F- Modes of transmission for HIV include blood, semen, saliva, and casual contact.

False

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

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 substance may be used to lubricate a condom?

K-Y jelly

T or F- The majority of primary immune deficiency disorders are diagnosed during infancy.

True

Kaposi sarcoma (KS) is diagnosed through

biopsy

Immune deficiency disorders may be caused by a defect in, or a deficiency of, phagocytic cells, B lymphocytes, T lymphocytes, or the ______________ system.

complement

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse knows which body fluid is not a means of transmission?

urine

A common complication of stage 3 HIV infection, _________________, is defined as a loss of more than 10% of one's body weight over a 30 day timeframe.

wasting syndrome

T or F- Many patients with PIDDs have comorbid autoimmune disorders, such as thyroid disease, rheumatoid arthritis, cytopenias, and inflammatory bowel disease.

True

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."

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

Liquids

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

Longer survival

The majority of patient with primary immunodeficiency are in which age group?

Younger than 20

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

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 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 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

A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching?

Caregiver cleans the client's anal area without wearing gloves

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."

_________________ is a clinical syndrome that is characterized by a progressive decline in cognitive, behavioral, and motor functions as a direct result of HIV infection.

HIV encephalopathy

A secondary immunodeficiency is characterized by the following. Choose all that apply.

It usually occurs as a result of underlying disease processes. It frequently is caused by certain autoimmune disorders. It may be caused by certain viruses.

T or F- Nursing management of patients with HIV include educating the patient to recognize the signs and symptoms of infection.

True

T or F- Nurses need to be nonjudgmental in order to be effective in educating LGBT population about HIV/AIDS prevention methods.

True

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."

When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?

Risk for infection related to altered immune cell function