HIV

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation) SHORT ANSWER 1. The nurse is to give a client ganciclovir (Cytovene) for cytomegalovirus (CMV) retinitis. The dosage is 5 mg/kg IV every 12 hours. The client weighs 185 pounds. How many milligrams of ganciclovir does the client receive per dose? mg/dose

420 185 lb 1 kg/2.2 lb 5 mg/kg = 420 mg/dose DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Implementation) 2. The nurse is to give a client rifampin (Rifadin) for tuberculosis. The dosage is 10 mg/kg/day. The client weighs 198 lb, and the medication is available in 150-mg capsules. How many capsules of rifampin does the client receive daily? __________ capsules/day

6 198 lb 1 kg/2.2 10 mg/kg = 900 mg 1 capsule/150 mg = 6 capsules/day DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Implementation 1. A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient? a. The EIA test will need to be repeated to verify the results. b. A viral culture will be done to determine the progression of the disease. c. It will probably be 10 or more years before you develop acquired immunodeficiency syndrome (AIDS). d. The Western blot test will be done to determine whether acquired immunodeficiency syndrome (AIDS) has developed.

A After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not usually part of HIV testing. It is not appropriate for the nurse to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with the Interdisciplinary Team) MSC: Integrated Process: Caring 21. The nurse is caring for a client who is HIV positive. The client has become confused over the course of the shift, and the clients pupils are no longer reacting to light equally. The nurse anticipates an order for which medication? a. Prednisone (Deltazone) b. Trimethoprim/sulfamethoxazole (Bactrim) c. Pentamidine isethionate (Pentam) d. Ketoconazole (Nizoral)

A Confusion and changes in pupillary assessment in an HIV-positive client indicate increased intracranial pressure (ICP). Increased ICP in these clients is managed with corticosteroids like prednisone. Bactrim is an antibiotic, Pentam is an antiprotozoal, and Nizoral is an antifungal medication. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation) 2. The nurse is caring for a young client who has acquired immune deficiency syndrome (AIDS) and a very low CD4+ cell count. The nurse is teaching the client how to avoid infection at home. Which statement by the client indicates that additional teaching is needed? a. I will let my sister clean my pet iguanas cage from now on. b. My brother will change the kitty litter box from now on. c. It will seem funny but Ill run my toothbrush through the dishwasher. d. I will not drink juice that has been sitting out for longer than an hour.

A Immune compromised clients should avoid having reptiles or turtles as pets and should avoid changing cat litter to help prevent opportunistic infections. Drinking juice that has been at room temperature for longer than 1 hour can lead to opportunistic infection and should be avoided. Clients should clean their toothbrushes daily by running them in the dishwasher or rinsing them in liquid laundry bleach. DIF: Cognitive Level: Application/Applying or higher

p. 360 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Teaching/Learning 4. The nurse is caring for a young woman at the primary health care clinic. Which assessment finding leads the nurse to question the client about risk factors for HIV? a. Six vaginal yeast infections in the last 12 months b. Unable to become pregnant for the last 2 years c. Severe cramping and irregular periods d. Very heavy periods and breakthrough bleeding

A Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women. Decreased immune function allows overgrowth of this fungus. Infertility, heavy periods, and cramping are not generally indicative of HIV. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 25. A nursing assistant asks the nurse if respiratory isolation is needed for a client with Pneumocystis jiroveci pneumonia. What is the nurses best response? a. This type of pneumonia is an opportunistic infection, so the staff is not at risk. b. You should wear a mask and a gown to provide care. c. Yes, please institute respiratory isolation because this is very contagious. d. You are not at risk for this infection if you have had a vaccination.

A Pneumocystis jiroveci pneumonia is an opportunistic infection that will not cause disease in staff with healthy immune systems. Standard Precautions should be used for this client. Contact, Airborne, or Droplet Precautions are not indicated for this client. Health care staff do not get vaccinated for this infection. DIF: Cognitive Level: Application/Applying or higher

232 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patients human immunodeficiency virus (HIV) status is unknown? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with patient vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure

A Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patients blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus. DIF: Cognitive Level: Apply (application)

334 KEY: HIV/AIDS| nursing assessment| informed consent| NPO| endoscopy MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 1. Which action by the nurse is most effective to prevent becoming exposed to the human immune deficiency virus (HIV)? a. Always use Standard Precautions with all clients in the workplace. b. Place clients who are HIV positive in Contact Precautions. c. Wash hands before and after contact with clients who are HIV positive. d. Convert parenteral medications to an oral form for clients who are HIV positive.

A The best prevention for health care providers is the consistent use of Standard Precautions with all clients, as recommended by the Centers for Disease Control and Prevention (CDC). Contact Precautions are not indicated unless the client has an infection such as Clostridium difficile or MRSA (methicillin-resistant Staphylococcus aureus). DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 7. A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The clients purified protein derivative (PPD) test, placed 3 days ago in the clinic, is negative. Which action by the nurse is most appropriate? a. Place the client in Airborne Precautions. b. Facilitate the clients chest x-ray. c. Initiate a 3-day calorie count. d. Start an IV of normal saline.

A The clients symptoms are indicative of tuberculosis (TB). With AIDS, the clients CD4+ T-cell count is so low that the client cannot mount an immune response to the PPD; thus it appears negative. The client needs to be placed in Airborne Precautions until other diagnostic tests rule out TB. The other interventions are appropriate, but they do not take priority over infection control principles. DIF: Cognitive Level: Application/Applying or higher

234 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation

A The current Center for Disease Control (CDC) policy is to offer routine testing for HIV to all individuals age 13 to 64. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range. DIF: Cognitive Level: Apply (application)

237 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay

A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Teaching/Learning 9. A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, The doctor said that my viral load is reduced. What does this mean? What is the nurses best response? a. The HAART medications are working well right now. b. You are not as contagious as you were anymore. c. Your HIV infection is becoming resistant to your medications. d. You are developing an opportunistic infection.

A The fact that the amount of virus is reduced means that the HAART regimen is working well to suppress viral replication. The risk of becoming infected by an HIV-positive person is always present. The reduced viral load is not related to an opportunistic infection or to resistance to medication. DIF: Cognitive Level: Comprehension/Understanding

242 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 21. An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching? a. Many medications have interactions with antiretroviral drugs. b. Less frequent CD4+ level monitoring is needed in older adults. c. Hospice care is available for patients with terminal HIV infection. d. Progression of HIV infection occurs more rapidly in older patients.

A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient with asymptomatic HIV infection is not a candidate for hospice. Progression of HIV is not affected by age, although it may be affected by chronic disease. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications) MSC: Integrated Process: Caring 29. The nurse is caring for a client with HIV who has been prescribed didanosine (Videx EC). Which action by the nurse is most appropriate? a. Help the client plan specific meal and dosing times. b. Explain that the client will have frequent complete blood counts (CBCs) drawn. c. Advise the client to take Videx EC with milk or a small meal. d. Tell the client to take Tylenol (acetaminophen) for any abdominal pain.

A Videx EC must be taken on an empty stomach 30 minutes before or 2 hours after a meal. The nurse should assist the client in planning a daily schedule that includes meals and drug doses. Videx does not affect bone marrow, so frequent CBCs are not needed. A client on this drug who reports abdominal pain should be assessed for pancreatitis, a common adverse effect. DIF: Cognitive Level: Application/Applying or higher

341 KEY: HIV/AIDS| neuropathic pain| tricyclic antidepressants| pain| pharmacologic pain management MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 18. A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

A A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client. DIF: Applying/Application

330 KEY: HIV/AIDS| safer sex| infection| immune disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client

A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact. DIF: Remembering/Knowledge

328 KEY: HIV/AIDS| safer sex| immune disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 2. The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

A Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus. DIF: Understanding/Comprehension

334 KEY: HIV/AIDS| Transmission-Based Precautions| infection control| immune disorders MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

A The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the clients sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate. DIF: Applying/Application

344 KEY: HIV/AIDS| communication| advocacy| caring| patient-centered care MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 14. A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

A The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve. DIF: Applying/Application

336 KEY: HIV/AIDS| autonomy| advocacy| referrals| LGBTQ MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.

A The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms. DIF: Applying/Application

343 KEY: HIV/AIDS| nursing assessment| psychosocial response| support| caring MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity 13. A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.

A The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything. DIF: Applying/Application

1. The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

A This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease. DIF: Applying/Application

334 KEY: HIV/AIDS| infection control| Standard Precautions MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

A This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know. DIF: Applying/Application

338 KEY: HIV/AIDS| immune disorders| prioritizing| fever| infection| white blood cell count MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 19. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.

A Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis. DIF: Understanding/Comprehension

232 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred. DIF: Cognitive Level: Apply (application)

332 KEY: HIV/AIDS| immune disorders| vaccinations| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease. DIF: Remembering/Knowledge

328 KEY: HIV/AIDS| immune disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

A, B, C, D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding. DIF: Analyzing/Analysis

327 KEY: HIV/AIDS| immune disorders| inflammation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

A, B, D A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics. DIF: Remembering/Knowledge

230 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 3. The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a. Continue taking antibiotics until all the medication is gone. b. Antibiotics may sometimes be prescribed to prevent infection. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

A, B, E All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a future infection. Hand washing is generally considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza. DIF: Cognitive Level: Apply (application)

341 KEY: HIV/AIDS| delegation| hygiene| elimination| patient safety| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the clients mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the clients abdomen.

A, C, D Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure. DIF: Applying/Application

332 KEY: HIV/AIDS| infection control| culture| patient-centered care MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Psychosocial Integrity 4. A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L

A, D, E The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal. DIF: Analyzing/Analysis

237 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient about how to use tissues to dispose of respiratory secretions. b. Stock the patients room with all the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patients family members the reason for the use of airborne precautions.

B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application)

p. 361 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Teaching/Learning 17. A client has selective immune globulin A (IgA) deficiency. The provider orders an infusion of immune globulin (IVIG). Which action by the nurse is best? a. Start a second IV line for the clients antibiotics. b. Call the physician to clarify the order. c. Review the clients renal panel before administration. d. Obtain baseline vital signs and another set after 15 minutes.

B Clients with selective IgA deficiency are not treated with IVIG because it contains very little IgA, and because the risk of allergic reactions is high. The nurse should contact the provider to clarify what medications the client will be taking. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Planning) 13. The nurse is teaching a client how to prevent transmitting HIV to his sexual partner. Which statement by the client indicates that additional teaching is needed? a. I can throw the condoms in the trash after I have used them. b. I will store my condoms in my wallet so they are always handy. c. Water-based lubricants are best to prevent condom breakage. d. The condom needs to stay on until I withdraw my penis.

B Condoms should be stored in a cool, dry place. Wallets are not recommended because body heat can weaken the latex in the condom. The condom should stay on the penis until it is completely withdrawn. Condoms should be used only once and then discarded. Oil-based lubricants can weaken latex, possibly causing tearing or leakage, so only water-based lubricants are recommended. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 6. The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis. Which is the best nursing intervention for this client? a. Initiate respiratory isolation for the next 72 hours. b. Initiate seizure precautions with padded siderails. c. Thicken the clients liquids to honey consistency. d. Administer IV pentamidine isethionate (Pentam).

B Cryptococcosis is a debilitating form of meningitis that can cause seizures, so seizure precautions should be initiated. Respiratory isolation is not indicated. Dysphagia is not seen with cryptococcal meningitis, so thickened liquids are not indicated. Pentam is given for Pneumocystis jiroveci pneumonia (PJP). DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Analysis) 8. The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide (Fuzeon). Which precaution is important for the nurse to communicate to this client? a. Stop taking the medication if you develop a fever. b. Rotate the sites where you will be giving the injections. c. Take this medication with a snack or a small meal. d. Do not drive or operate machinery while taking this drug.

B Fuzeon is available only as a subcutaneous injection and can cause injection site reactions and nodules. The client should be taught the subcutaneous technique, including rotation of sites. The client should not stop taking this medication for fever, it can be given without regard to food, and the drug will not make the client sleepy or drowsy, so caution with driving or operating machinery is not needed. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors) MSC: Integrated Process: Teaching/Learning 14. The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a student indicates that additional teaching is required? a. A woman can still get pregnant if she is HIV positive. b. I wont get HIV if I only have oral sex with my partner. c. Showering after intercourse will not prevent HIV transmission. d. People with HIV are still contagious even if they take HAART drugs.

B HIV may be transmitted via oral sex when mucous membranes or nonintact skin comes in contact with infected body fluids (semen or vaginal secretions) or blood. Women who are HIV positive may get pregnant, and showering after intercourse will not reduce the risk of HIV transmission. HAART will lower viral loads, but the client will still be able to transmit the HIV virus to others. DIF: Cognitive Level: Application/Applying or higher

p. 362 TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors) MSC: Integrated Process: Teaching/Learning 23. The nursing supervisor is working with an HIV-positive nurse who has open weeping blisters on her arms after being exposed to poison ivy. Which instructions should the nursing supervisor provide to the nurse before she starts her shift? a. You should reassure your clients that you are not contagious. b. You should work phone triage at the desk today rather than taking clients. c. You should wear a long-sleeved scrub jacket today while working with clients. d. You should not care for clients who are immune compromised or in isolation.

B HIV-positive health care workers should not perform direct client care when they have open sores. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 18. The nurse is working with a client who has AIDS-related dementia and will soon be discharged to the care of family members. What teaching topic is best for the nurse to include in the discharge plan? a. Feed the client when he will not do it by himself. b. Make sure that a clock and a calendar are easily visible. c. Remove locks from bathroom and bedroom doors. d. Do not allow the client to smoke when he is alone.

B Having a clock and a calendar easily visible will help the client keep track of the date and time and will assist with reorientation. Banning smoking, removing locks, and feeding the client will not facilitate reorientation when the client is confused. DIF: Cognitive Level: Application/Applying or higher

243 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 16. The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time? a. Oral acyclovir (Zovirax) b. Oral saquinavir (Invirase) c. Nystatin (Mycostatin) tablet d. Aerosolized pentamidine (NebuPent)

B It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day. DIF: Cognitive Level: Apply (application)

p. 362 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning 11. An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate? a. Renal function studies b. Liver enzymes c. Blood glucose monitoring d. Albumin and prealbumin

B Kaletra can cause liver complications, and clients taking it should have liver function studies. The clients symptoms could indicate a liver problem. Renal function and blood glucose are not affected by Kaletra. The client may have an albumin and a prealbumin drawn if he or she has lost a great deal of weight and malnutrition is suspected, but the more common diagnostic test for a client taking Kaletra would be liver function studies. DIF: Cognitive Level: Application/Applying or higher

241 | 244 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, I am very nervous about making my baby sick. Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART).

B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided. DIF: Cognitive Level: Understand (comprehension)

241 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 12. A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. Avoid sexual intercourse when using injectable drugs. b. It is important to participate in a needle-exchange program. c. You should ask those who share equipment to be tested for HIV. d. I recommend cleaning drug injection equipment before each use.

B Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs. DIF: Cognitive Level: Apply (application)

242 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 19. Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/L and an undetectable viral load. What is the priority nursing intervention at this time? a. Teach about the effects of antiretroviral agents. b. Encourage adequate nutrition, exercise, and sleep. c. Discuss likelihood of increased opportunistic infections. d. Monitor for symptoms of acquired immunodeficiency syndrome (AIDS).

B The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection, when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART. DIF: Cognitive Level: Apply (application)

p. 361 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 5. A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first? a. Assess the clients deep tendon reflexes. b. Ask the client to place his chin on his chest. c. Start an IV line with normal saline. d. Assess the clients pupil reaction.

B The clients symptoms are associated with cryptococcal meningitis, so the nurse should first ask the client to place the chin on his or her chest. The presence of nuchal rigidity (pain when flexing the chin to the chest) helps confirm the diagnosis. An IV line may be started after the neurologic assessment is completed. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis) 22. A client verbalizes a fear of contracting HIV because she has a history of intravenous substance abuse. What instructions does the nurse provide to the client to help minimize this risk? a. Boil all needles and syringes for at least 20 minutes before using them again and be sure not to share them. b. Rinse used needles and syringes with water followed by laundry bleach after using them. c. Rinse used needles and syringes with rubbing alcohol before and after using them. d. Run all needles and syringes through the dishwasher with an extra rinse cycle before using them again.

B To minimize the risk for HIV transmission, needles should be cleaned with laundry bleach after use. Boiling needles and syringes and rinsing with alcohol are not recommended. Running needles and syringes through the dishwasher will not sanitize them sufficiently. The client should be encouraged not to share needles and syringes. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 16. The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The client states, Im an old woman! I cannot possibly get HIV. What is the nurses best response? a. Your vaginal walls become thicker after menopause, which increases your risk. b. Women in your age-group are the fastest growing population of AIDS clients today. c. Hormonal fluctuations after menopause make it harder to fight off infection. d. You might be right. How often do you engage in sexual activities?

B Women are the fastest growing group with HIV infection and AIDS. Infection with HIV can occur at any age, and postmenopausal women experience thinning of vaginal tissue along with an age-related (not hormonal) decline in immune function. This places the older woman at higher risk of acquiring HIV infection. The frequency of sexual activity is not as relevant as the sexual activities the person practices. DIF: Cognitive Level: Comprehension/Understanding

336 KEY: HIV/AIDS| safer sexual practices| nursing assessment| immune disorders MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

B Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed. DIF: Applying/Application

339 KEY: HIV/AIDS| immune disorder| antiretrovirals| HAART MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

B Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment. DIF: Applying/Application

342 KEY: HIV/AIDS| wound care| dressings| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management? a. Infusions will be scheduled every 3 to 4 weeks. b. Treatment is aimed at treating specific infections. c. Unfortunately, there is no effective treatment. d. You will need many immunoglobulin A infusions.

B Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate. DIF: Understanding/Comprehension

238 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. According to the Center for Disease Control (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium difficile(select all that apply)? a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

B, C Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines. DIF: Cognitive Level: Apply (application)

341 KEY: HIV/AIDS| delegation| unlicensed assistive personnel (UAP)| oral care MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the clients fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

B, C, D, E The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status. DIF: Applying/Application

340 KEY: HIV/AIDS| laboratory values| antibiotics| immune disorders MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

B, C, E The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE 1. The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select all that apply.) a. Use sterile gloves and gowns whenever the nursing staff is in contact with the client. b. Provide an incentive spirometer to encourage coughing and deep breathing by the client. c. Keep a blood pressure cuff, thermometer, and stethoscope in the clients room for his or her use only. d. Use N95 respirators (all nursing staff) when in the clients room. e. Request that the family take home the fresh flowers that are at the clients bedside. f. Assist the client with meticulous oral care after meals and at bedtime.

B, C, E, F The nursing staff should encourage coughing and deep breathing to prevent pneumonia, and incentive spirometry will be helpful. Assessment equipment such as thermometers and blood pressure cuffs should be kept in the room only for the use of this client, rather than being used by other clients on the unit as well. Fresh flowers can harbor microorganisms and should be removed from the room. Meticulous oral care will help to prevent infection by Candida. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 3. The nurse is working with a client at a public health clinic. The client says to the nurse, The doctor said that my CD4+ count is 450. Is that good? What is the nurses best response? a. Your count is high so you can cut back on your medication. b. Your count is normal because your medications are working well. c. Your count is a bit low and you are susceptible to infection. d. Your count is very low and you actually now have AIDS.

C A CD4+ T-cell count of 450 cells/mm3 of blood is low, and the client is at increased risk for developing an infection. Normal CD4+ counts range from 800 to 1000 cells/mm3. To be diagnosed with AIDS, a client must have a CD4+ T-cell count of <200 cells/mm3 (or a CD4+ T-cell percentage of <4%) and/or an opportunistic infection. DIF: Cognitive Level: Comprehension/Understanding

236 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem. DIF: Cognitive Level: Apply (application)

235 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient about the medications available for treatment. b. Inform the patient how to protect sexual and needle-sharing partners. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to notify individuals who have had risky contact with the patient.

C After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals. DIF: Cognitive Level: Apply (application)

p. 370 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Communication and Documentation 10. The nurse is seeing clients at a drop-in primary health clinic. Which client does the nurse teach about the risks of acquiring HIV? a. Middle-aged woman with a new sexual partner b. Young male who has male sexual partners c. All clients who come to the clinic d. Young woman having her first gynecologic examination

C All sexually active people should know their HIV status, and all people need to have education on their risk of acquiring HIV infection. Anyone who engages in sexual activity has some risk. DIF: Cognitive Level: Knowledge/Remembering

236 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. The patient meets the criteria for a diagnosis of an acute HIV infection. b. The patient will be diagnosed with asymptomatic chronic HIV infection. c. The patient has developed acquired immunodeficiency syndrome (AIDS). d. The patient will develop symptomatic chronic HIV infection in less than a year.

C Development of PCP meets the diagnostic criterion for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection. DIF: Cognitive Level: Understand (comprehension)

232 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Driving is allowed when starting this medication. b. Report any bizarre dreams to the health care provider. c. Continue to use contraception while on this medication. d. Take this medication in the morning on an empty stomach.

C Efavirenz can cause fetal anomalies and should not be used in patients who may be pregnant. The drug should not be used during pregnancy because large doses could cause fetal anomalies. Once-a-day doses should be taken at bedtime (at least initially) to help patients cope with the side effects that include dizziness and confusion. Patients should be cautioned about driving when starting this drug. Patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Psychosocial Integrity (Behavioral Interventions) MSC: Integrated Process: Teaching/Learning 19. A client with HIV who is taking highly active antiretroviral therapy (HAART) medications is in radiology waiting for a chest x-ray when medications are due. What action by the nurse is best? a. Call radiology to see when the client will be brought back to the nursing unit. b. Send the nursing assistant to radiology to bring the client back to the nursing unit. c. Take the clients medications to radiology and administer them there if possible. d. Stagger the next dose of the medication if the current dose is given late.

C HAART medications must be given on time and in the correct dose when an HIV client is in the hospital. Missing or delaying even a few doses can lead to drug resistance. The best option would be for the nurse to administer the medications in radiology as the client continues to wait for the x-ray. Calling the radiology department might give the nurse information but does not ensure that the client receives the medication on time. Bringing the client back to the nursing unit might delay the x-ray. DIF: Cognitive Level: Application/Applying or higher

235 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10. The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Advise the patient that this is probably the flu. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.

C Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Applying ice to the neck may provide comfort, but the initial action is to reassure the patient this is an expected finding. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu. DIF: Cognitive Level: Apply (application)

230-231 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 23. The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation) 26. When obtaining a sexual history from a client in a clinic setting, the nurse notes that the client appears very uncomfortable and pauses for long periods before answering the nurses questions. What is the nurses best response? a. I am sorry that my questions are making you very uncomfortable. b. Dont worry. Well be done with these questions in no time at all. c. Take your time. I realize that this is a very private topic to talk about. d. These questions are making you uncomfortable, so well finish next time.

C The client should be given time to collect his or her thoughts and composure before answering questions. The nurse should not apologize for asking pertinent questions about the clients health history. The sexual history should not be deferred until the next appointment. Recognizing the difficulty the client may be experiencing is helpful in establishing a therapeutic relationship. DIF: Cognitive Level: Application/Applying or higher

234 | 242 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose latest CD4+ count is 250/L b. Patient whose rapid HIV-antibody test is positive c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs

C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock. DIF: Cognitive Level: Analyze (analysis)

N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications) MSC: Integrated Process: Caring 27. The nurse asks a young adult client if she is sexually active. The client asks why the nurse needs to know. What is the nurses best response? a. I just need to make sure that the information you are providing is reliable. b. I have to fill in answers to all of the questions on the health history form. c. If you are sexually active, we should talk about ways to prevent getting HIV. d. I will have to notify your partner if you have a sexually transmitted disease.

C The nurse should assess whether the client is sexually active to determine whether it is appropriate to teach about safer sex practices. The nurse would not notify the clients sexual partners if a sexually transmitted disease were diagnosed. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness) MSC: Integrated Process: Caring 28. The nurse is completing a health history for a client and begins to obtain a sexual history. What is the nurses best opening question? a. How long have you been sexually active? b. Are you in a monogamous relationship with your spouse? c. How do you feel about answering questions about your sexual history? d. Have you noticed any problems with your ability to have or enjoy sex?

C The nurse should begin with an assessment of the clients comfort level with the topic. The nurse should not assume that the client is sexually active or start with questions about the clients spouse. The nurse also should not use words like monogamous, which frequently are misunderstood by the public. The question about sexual ability and enjoyment is a closed-ended question, and if the client answers no, it will be awkward for the nurse to continue discussing this topic. DIF: Cognitive Level: Application/Applying or higher

334 KEY: HIV/AIDS| nursing assessment| fluids and electrolytes MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 17. A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug. c. This drug helps treat the pain from nerve irritation. d. You are at risk for seizures due to fungal infections.

C Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client. DIF: Understanding/Comprehension

332 KEY: HIV/AIDS| infection control| Standard Precautions| immune disorders MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

C Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case. DIF: Applying/Application

241 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 18. The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patients blood glucose level is 142 mg/dL. b. The patient complains of feeling constantly tired. c. The patient is unable to state the side effects of the medications. d. The patient states, Sometimes I miss a dose of zidovudine (AZT).

D Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common side effects of ART. The nurse should discuss medication side effects with the patient, but this is not as important as addressing the skipped doses of AZT. DIF: Cognitive Level: Apply (application)

242 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/L c. HIV-positive patient with a CD4+ count of 160/L who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

D CMV retinitis is an acquired immunodeficiency syndrome (AIDS)-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Planning) 24. The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in confirming progression of the clients diagnosis to AIDS? a. Generalized lymphadenopathy b. HIV-positive status for 8 years c. Low-grade fever for the last 10 days d. Thick white patches on the clients tongue

D Candidiasis, which presents with thick white patches on the tongue and oral mucosa, is associated with the development of AIDS after HIV infection. The fact that the client has been positive for 8 years or has a low-grade fever is not significant. DIF: Cognitive Level: Application/Applying or higher

238 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/L. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. HIV genotype and phenotype b. Patients social support system c. Potential medication side effects d. Patients ability to comply with ART schedule

D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART. DIF: Cognitive Level: Apply (application)

235-236 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 4. A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, I feel obsessed with thoughts about dying. Do you think I am just being morbid? Which response by the nurse is best? a. Thinking about dying will not improve the course of AIDS. b. It is important to focus on the good things about your life now. c. Do you think that taking an antidepressant might be helpful to you? d. Can you tell me more about the kind of thoughts that you are having?

D More assessment of the patients psychosocial status is needed before taking any other action. The statements, Thinking about dying will not improve the course of AIDS and It is important to focus on the good things in life discourage the patient from sharing any further information with the nurse and decrease the nurses ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patients feelings. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 12. The nurse has been exposed to HIV through splashing of urine from a client who is HIV positive with a low viral load. The urine came into contact with the nurses face. Which drug regimen does the nurse prepare to initiate? a. Retrovir (zidovudine) for 14 days b. Retrovir (zidovudine) for 28 days c. Retrovir (zidovudine) and Epivir (lamivudine) for14 days d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days

D The Centers for Disease Control and Prevention have developed guidelines for postexposure prophylaxis (PEP). This nurses exposure requires basic PEP with two drugs for 28 days. DIF: Cognitive Level: Application/Applying or higher

240 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 13. Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patients class schedule to help decide when the drugs should be taken.

D The best approach to improve adherence is to learn about important activities in the patients life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the patients schedule. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors) MSC: Integrated Process: Teaching/Learning 15. The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed? a. I will wash my hands whenever I get home from work. b. I will make sure to have my own tube of toothpaste at home. c. I will run my toothbrush through the dishwasher every evening. d. I will be sure to eat lots of fresh fruits and vegetables every day.

D The client should avoid eating raw fruits, vegetables, and salads because of the risk of infection. Hands should be washed whenever returning home, and immune compromised clients should not share toothbrushes or toothpaste. Toothbrushes should be run through the dishwasher nightly. DIF: Cognitive Level: Application/Applying or higher

242 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 14. A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.

D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Implementation) 20. An HIV-positive client verbalizes concerns about the high cost of antiretroviral medications. What is the nurses best response? a. The medications are actually less expensive than they used to be. b. These medications are the best course of treatment for you. c. You should be glad the medications will help prolong your life. d. Lets talk to the social worker about getting financial assistance for you.

D This response demonstrates the nurses role as client advocate by identifying resources to help meet the clients needs. The nurse should not belittle the clients concerns by telling the client to be glad the medications are working, or that they are less expensive than previously. DIF: Cognitive Level: Application/Applying or higher

341 KEY: HIV/AIDS| malnutrition| nutrition MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 9. A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

D All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital. DIF: Applying/Application

340 KEY: HIV/AIDS| immune disorders| rest and sleep| fatigue MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

D The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients. DIF: Evaluating/Synthesis

338 KEY: HIV/AIDS| nursing assessment| immune disorders| medications MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest.

D This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the clients activity. DIF: Applying/Application

345 KEY: Immune disorders| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

D Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client. DIF: Applying/Application