HIV PrepU32
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
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.
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? distal sensory polyneuropathy (DSP) candidiasis AIDS dementia complex (ADC) cytomegalovirus (CMV)
AIDS dementia complex (ADC) Explanation: ADC, a neurologic condition, causes the degeneration of the brain, especially in areas that affect mood, cognition, and motor functions. Such clients exhibit forgetfulness, limited attention span, decreased ability to concentrate, and delusional thinking. DSP is characterized by abnormal sensations, such as burning and numbness in the feet and later in the hands. Candidiasis is a yeast infection that may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in the folds of the skin. CMV infects the choroid and retinal layers of the eye, leading to blindness, and can also cause ulcers in the esophagus, colitis, diarrhea, pneumonia, and encephalitis.
A client with acquired immune deficiency syndrome (AIDS) informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the client has developed? MAC Wasting syndrome Kaposi's sarcoma Candidiasis
Candidiasis Explanation: Candidiasis, a fungal infection, occurs in almost all clients with AIDS and immune depression (Durham & Lashley, 2010). Oral candidiasis is characterized by creamy-white patches in the oral cavity and, if left untreated, can progress to involve the esophagus and stomach. Associated signs and symptoms include difficult and painful swallowing and retrosternal pain.
Which term defines the balance between the amount of HIV in the body and the immune response? Viral set point Window period Primary infection stage Viral clearance rate
Viral set point Explanation: The viral set point is 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.
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? Overall, these conditions more commonly affect females. Most cases are typically diagnosed in infancy. The conditions appear to predominate in males after adolescence. Primary immunodeficiencies are more common than secondary immunodeficiencies
Most cases are typically diagnosed in infancy. Explanation: Most primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1. A large fraction of primary immunodeficiencies are not diagnosed until adolescence or early adulthood when the gender distribution equalizes. Secondary immunodeficiencies are more common than primary immunodeficiencies.
Kaposi sarcoma (KS) is diagnosed through skin scraping. biopsy. visual assessment. computed tomography.
biopsy. Explanation: KS is diagnosed through biopsy of the suspected lesions. Visual assessment will not confirm a diagnosis. A computed tomography scan will not assist in determining skin cell changes. Skin scraping is a procedure to collect cells, not to evaluate cells.
The nurse assesses a client who is diagnosed with human immunodeficiency virus (HIV) for adverse reactions associated with the prescribed medication, abacavir. Drag words from the choices below to fill in each blank in the following sentence. The nurse provides emergency intervention when the client exhibits the following symptoms: , , and . Symptoms sore throat vomiting cough nausea diarrhea dyspnea
cough, dyspnea , sore throat Antiretroviral therapy (ART) is supported by evidence-based practice guidelines for the treatment of HIV; however, there are certain adverse reactions associated with nucleoside reverse transcriptase inhibitors (NRTIs), a type of ART, that the nurse must monitor for in the provision of client care. A client who is prescribed abacavir is at risk for anaphylaxis; thus, respiratory symptoms, including a sore throat, a cough, and/or dyspnea, require emergency action by the nurse. Although diarrhea, nausea, and vomiting are adverse reactions associated with abacavir and require additional monitoring, none of these findings require emergency intervention by the nurse.
The nurse is discussing sexual activity with a client recently diagnosed with human immunodeficiency virus (HIV). The client states, "As long as I have sex with another person who is already infected, I will be okay." What is the best response by the nurse? "You should avoid having unprotected sex with a person who is HIV positive because you can increase the severity of the infection in both you and your partner." "Yes, since you are already infected, it won't make a difference if you have sex with a person who is HIV positive." "I am not sure why you would want to have sex with another person who is HIV positive. That person may have another sexually transmitted infection." "If you have sex with another person who is HIV positive, you will develop AIDS sooner."
"You should avoid having unprotected sex with a person who is HIV positive because you can increase the severity of the infection in both you and your partner." Explanation: Clients, families, and friends are educated about the routes of transmission of HIV. The nurse discusses precautions the client can use to avoid transmitting HIV sexually or through sharing of body fluids, especially blood.
When a nurse infuses gamma globulin intravenously, the rate should not exceed 1.5 mL/min 3 mL/min 6 mL/min 10 mL/min
3 mL/min Explanation: The intravenous infusion should be administered at a slow rate, not to exceed 3 mL/min.
A client is infected with human immunodeficiency virus (HIV) after sharing needles with another intravenous (IV) drug abuser. Upon infection with HIV, the immune system responds by making antibodies against the virus, usually within how many weeks after infection? 1 to 2 weeks 3 to 6 weeks 3 to 12 weeks 6 to 18 weeks
3 to 12 weeks Explanation: When a person is infected with HIV, the immune system responds by producing antibodies against the virus, usually within 3 to 12 weeks after infection.
The development of a positive HIV antibody test following initial infection generally occurs in which timeframe? 4 weeks 6 weeks 8 weeks 10 weeks
4 weeks Explanation: Development of a positive HIV antibody test generally occurs within 4 weeks and with few exceptions by 6 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 12 weeks 18 weeks 24 weeks
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.
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: Anorexia. Chronic diarrhea. Nausea and vomiting. Oral candida.
Chronic diarrhea. Explanation: Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of AIDS can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.
More than 50% of individuals with this disease develop pernicious anemia: Bruton disease Common variable immunodeficiency (CVID) DiGeorge syndrome Nezelof syndrome
Common variable immunodeficiency (CVID) Explanation: More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions.
Which blood test confirms the presence of antibodies to HIV? Erythrocyte sedimentation rate (ESR) p24 antigen Reverse transcriptase Enzyme immunoassay (EIA)
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.
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? T-and C-cell assays Complete chemistry panel Enzyme-linked immunosorbent assay Plasmapheresis
Enzyme-linked immunosorbent assay Explanation: 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.
As part of HAART therapy, a client is prescribed a non-nucleoside reverse transcriptase inhibitor (NNRTI). What would be an example of a drug from this class? Select all that apply. Abacavir Delavirdine Amprenavir Efavirenz Stavudine
Examples of NNRTIs are delavirdine and efavirenz. Abacavir and stavudine are nucleoside reverse transcriptase inhibitors (NRTIs). Amprenavir is a protease inhibitor.
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 urine breast milk blood vaginal secretions
Explanation: 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 woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV? Rashes on the face, trunk, palms, and soles Muscle and joint pain Gynecologic problems Weight loss
Gynecologic problems Explanation: In women with HIV, gynecologic problems, such as abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may be the focus of a majority of complaints. Acute retroviral syndrome (viremia) may be the chief complaint in one third to more than one half of those infected, not necessarily women. Its manifestations include rashes, muscle and joint pain, and weight loss.
When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic? means of transmission HIV-1 is more prevalent than HIV-2 subtypes the fact that it is a mutated virus originally thought to be bovine in nature cure rate
HIV-1 is more prevalent than HIV-2 subtypes Explanation: 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.
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started? Antibiotic therapy Immunosuppressive agents Chest physiotherapy Anticoagulation
Immunosuppressive agents Explanation: For a client undergoing a hematopoietic stem cell transplant, immunosuppression is started to ensure engraftment of depleted bone marrow. Antibiotic therapy may or may not be indicated. Chest physiotherapy would be appropriate for clients with ataxia-telangiectasis who have chronic lung disease. Anticoagulation would not be used.
What does the nurse understand will result if the patient has a deficiency in the normal level of complement? Increased susceptibility to infection Decrease in vascularity to the extremities Development of congestive heart failure Risk of stroke
Increased susceptibility to infection Explanation: The complement system is an integral part of the immune system, and deficiencies in normal levels of complement result in increased susceptibility to infectious diseases and immune-mediated disorders.
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS? Liquids Gluten Sucrose Iron and zinc
Liquids Explanation: The nurse should encourage clients with AIDS to consume liquids in order to help replace fluid and electrolyte losses. Gluten and sucrose may increase the complication of malabsorption. Large doses of iron and zinc should be avoided because they can impair immune function.
The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurrence) in persons with AIDS? Cytomegalovirus Legionnaire's disease Mycobacterium tuberculosis Pneumocystis pneumonia
Pneumocystis pneumonia Explanation: Pneumocystic pneumonia (PCP) is one of the first and most common opportunistic infections associated with AIDS. It may be present despite the absence of crackles. If untreated, PCP progresses to cause significant pulmonary impairment and respiratory failure.
The period from infection with HIV to the development of antibodies to HIV is known as which of the following? Primary infection Viral load Viral set point Anergy
Primary infection Explanation: Primary infection is the period from the infection with HIV to the development of antibodies to HIV. The viral load test measures plasma HIV RNA levels. Viral set point is the balance between the amount of HIV in the body and the immune response. Anergy is the absence of an immune response.
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
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.
What test will the nurse assess to determine the client's response to antiretroviral therapy? Western blotting Viral load Enzyme immunoassay Complete blood count
Viral load Explanation: Viral load should be measured at baseline and on a regular basis thereafter because viral load is the most important indicator of response to ART. The other tests are not used in this way.
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.
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.
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.
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 with acquired immune deficiency syndrome (AIDS) reports diarrhea after every meal. What is the nurse's best response? Avoid residue, lactose, fat, and caffeine. Encourage large, high-fat meals. Reduce food intake. Increase the intake of iron and zinc.
Avoid residue, lactose, fat, and caffeine. Explanation: Diarrhea may subside when the client avoids residue, lactose, fat, and caffeine. Although eating may seem to cause diarrhea, the client must understand that limiting the intake of food to control diarrhea only exacerbates wasting. The client will tolerate a low-fat, high-carbohydrate, soft or liquid diet better than large, high-fat meals. The client should be advised to avoid large doses of iron and zinc because they can impair the functioning of the immune system.
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 probably has a case of the flu and you should give acetaminophen." "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." "This is one of the side effects from antiretroviral therapy and will require changing the medication." "The client probably has pneumocystis pneumonia and will need to be evaluated by the health care provider."
"The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." Explanation: 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 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
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 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? Cleavage Budding Attachment Uncoating
Attachment Explanation: Once HIV enters the host cell, attachment occurs in which the glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors. This is followed by uncoating, in which HIV's viral core is emptied into the CD4+ T cell. Cleavage and budding occur as the last steps.
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 DAF CVID SCID
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.
When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following? Antibodies to HIV are not present in his blood. He has not been infected with HIV. He is immune to HIV. Antibodies to HIV are present in his blood.
Antibodies to HIV are not present in his blood. Explanation: A negative test result indicates that antibodies to HIV are not present in the blood at the time the blood sample for the test is drawn. A negative test result should be interpreted as demonstrating that if infected, the body has not produced antibodies (which take from 3 weeks to 6 months or longer). Therefore, subsequent testing of an at-risk patient must be encouraged. The test result does not mean that the patient is immune to the virus, nor does it mean that the patient is not infected. It just means that the body may not have produced antibodies yet. When antibodies to HIV are detected in the blood, the test is interpreted as positive.
A client is to self-administer intravenous immunoglobulin (IVIG) in the home. What is the client's first action? Prepare the IVIG solution. Check the IV device patency. Take the premedication. Check his or her temperature.
Check the IV device patency. Explanation: 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.
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? Sharing the diagnosis with a support group Caring for a client who can kill other people Disclosure of the client's condition Caring for a client with an infectious terminal disease
Disclosure of the client's condition Explanation: 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.
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family? How to promote immune function through nutrition The importance of maintaining the client's vaccination status How to choose antibiotics based on the client's symptoms The need to report any slight changes in the client's health status
The need to report any slight changes in the client's health status Explanation: 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 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? Mouth sores Sneezing Constipation Tickle in the throat
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.
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."
"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.
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 wash my hands whenever I get home from work." "I will make sure to have my own toothbrush and tube of toothpaste at home." "I will avoid contact with people who are sick or who have recently been vaccinated." "I will be sure to eat lots of fresh fruits and vegetables every day."
"I will be sure to eat lots of fresh fruits and vegetables every day." Explanation: The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.
A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action? Encourage the client to drink more fluids. Administer fluids 100 mL/hour IV. Assess blood urea nitrogen and creatinine. Assess liver function tests.
Assess blood urea nitrogen and creatinine. Explanation: Adverse effects associated with antiretroviral therapy include potential nephrotoxicity. Assessing blood urea nitrogen and creatinine for clients who have decreased urination is appropriate. The other answers will not assist the nurse in determining the client's problem, which should be assessed before intervention are administered.
The nurse is caring for a client whose most recent laboratory values reveal a neutrophil level of 21,000 mm3. When preparing to assess the client, the nurse should prioritize what assessment? Assessing the client for signs and symptoms of infection Assessing the client's activity level and functional status Assessing the client for indications of internal or external hemorrhage Assessing the client for signs of venous thromboembolism
Assessing the client for signs and symptoms of infection Explanation: Normal neutrophil levels range from 3,000 to 7,000 mm3. Levels rise in response to infection, so the nurse should monitor the client closely for signs and symptoms of infection. Increased neutrophil levels do not normally affect coagulation or energy levels.
A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring? Delayed hypersensitivity response Anaphylactic reaction Sensitization An immediate hypersensitivity response
Delayed hypersensitivity response Explanation: A delayed hypersensitivity response may develop over several hours or days, or it may reach maximum severity after repeated exposure. Examples of a delayed hypersensitivity response include a blood transfusion reaction that occurs days to weeks after blood administration, rejection of transplanted tissues, and reaction to a tuberculin skin test. Anaphylaxis is a rapid and profound type I hypersensitivity response. Sensitization is the process by which cellular and chemical events occur after a second or subsequent exposure to an allergen. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly.
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? Lifestyle actions that improve immune function Educational programs that focus on control and prevention Appropriate use of standard precautions Screening programs for youth and young adults
Educational programs that focus on control and prevention Explanation: 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.
Which of the following indicates that a client with HIV has developed AIDS? Severe fatigue at night Pain on standing and walking Weight loss of 10 lb over 3 months Herpes simplex ulcer persisting for 2 months
Herpes simplex ulcer persisting for 2 months Explanation: A diagnosis of AIDS cannot be made until the person with HIV meets case criteria established by the Centers for Disease Control and Prevention. The immune system becomes compromised. The CD4 T-cell count drops below 200 cells and develops one of the opportunistic diseases, such as Pneumocystis carinii pneumonia, candidiasis, cytomegalovirus, or herpes simplex.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? Bathing or hygiene self-care deficit Ineffective cerebral tissue perfusion Complicated grieving Risk for injury
Risk for injury Explanation: 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 nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits what behavior? The nurse wears face protection, gloves, and a gown when irrigating a wound. The nurse performs hand hygiene with a waterless antiseptic agent after removing a pair of soiled gloves. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.
The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. Explanation: 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 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: p24 antigen test for confirmation of diagnosis. Western blot test for confirmation of diagnosis. polymerase chain reaction test for confirmation of diagnosis. T4-cell count for confirmation of diagnosis.
Western blot test for confirmation of diagnosis. Explanation: The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.
