Immune 1/10

A young gay patient being treated for his third sexually transmitted disease does not see why he should use condoms, because "they don't work." Which is the most appropriate response?

"Condoms may not provide 100% protection, but when used correctly and consistently with every act of sexual intercourse they reduce your risk of getting infected with HIV or other sexually transmitted diseases."

A patient has just been diagnosed as HIV-positive. He asks the nurse, "Does this mean I have AIDS?" Which response would be most informative?

"It varies with every individual, but the average time is 8 to 10 years from the time a person is infected, and some go much longer."

A 28-year-old married attorney with one child is in the first trimester of her second pregnancy. The patient states that she is at no risk for HIV, so she would not need to be counseled about testing for HIV. Which is the most appropriate response?

"The fastest-growing segment of the population with AIDS is women and children. We need to assess her risks."

The anxious male patient is fearful that he has been exposed to a person with an HIV infection. He states he does not want to go to a laboratory for the ELISA tests because he does not want to be identified. What would be the nurse's most helpful response?

"There is an FDA-approved home test called OraQuick."

When assigned to a newly admitted patient with AIDS, the nurse says, "I'm pregnant. It is not safe for me or my baby if I am assigned to his case." Which is the most appropriate response by the charge nurse?

"This patient would not be a risk for your baby if you use standard precautions and avoid direct contact with blood or body fluids."

A nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse understands that which problem is a priority for the client? 1. Infection 2. Inability to cope 3. Lack of information about the disease 4. Feeling uncomfortable about body changes

1. Infection Rationale: The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection. The question presents no data indicating that options 2, 3, or 4 are a problem.

The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1. Protecting the client from infection Rationale: The client with immune deficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

The client with acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which of the following procedures will be done to confirm whether these lesions are due to Kaposi's sarcoma? 1. Skin biopsy 2. Lung biopsy 3. Western blot 4. Enzyme-linked immunosorbent assay

1. Skin biopsy Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status.

A client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a nursing diagnosis of Impaired Gas Exchange written in the plan of care. Which of the following indicates that the expected outcome of care has not yet been achieved? 1. The client limits fluid intake. 2. The client has clear breath sounds. 3. The client expectorates secretions easily. 4. The client is free of complaints of shortness of breath.

1. The client limits fluid intake. Rationale: The status of the client with a nursing diagnosis of Impaired Gas Exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include that the client breathes easier, coughs up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

7. A client with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine (Videx) therapy. The clinic nurse emphasizes what instruction to this client? 1. Take crackers and milk with each dose of the medication. 2. Come to the health care clinic to be seen by the health care provider. 3. Decrease the dose of the medication until the next clinic visit. 4. This is an uncomfortable but expected side effect of the medication.

2. Come to the health care clinic to be seen by the health care provider. Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine (Videx). The client should be seen by the health care provider and be monitored for indications of developing pancreatitis. The reported symptoms are not the primary subject, and so the options directed toward explaining or managing them are not correct. The nurse should not encourage the client to alter the medication dose without first notifying the health care provider.

7. A client with acquired immunodeficiency syndrome (AIDS) is taking didanosine (Videx). The client calls the nurse at the health care provider's office and reports nausea, vomiting, and abdominal pain. Which of the following instructions would the nurse provide to the client? 1. This is an expected side effect of the medication. 2. Come to the office to be seen by the health care provider. 3. Take crackers and milk with the administration of the medication. 4. Decrease the dose of the medication until the next health care provider's visit.

2. Come to the office to be seen by the health care provider. Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides, decreased serum calcium, and nausea, vomiting, or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The client should be seen by the health care provider.

A nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which of the following is the priority concern for this client? 1. Inability to care for self at home 2. Development of an infection 3. Lack of available support services 4. Isolation

2. Development of an infection Rationale: Acquired immunodeficiency syndrome decreases the body's immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body's defense system. Opportunistic infections are a primary cause of death in people affected with AIDS. Therefore preventing infection is a priority of nursing care. Although the concerns in options 1, 3, and 4 may need to be addressed at some point in the care of the client, these are not the priority.

A client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. Which of the following would the nurse anticipate to be prescribed for the client? 1. Reduction in the medication dosage 2. Discontinuation of the medication 3. The administration of prednisone concurrent with the therapy 4. Administration of epoetin alfa (Epogen)

2. Discontinuation of the medication Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wear a gown and gloves to change the bed linens and gloves only for the bath

2. Wearing a gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

Indinavir (Crixivan) is prescribed for a client with human immunodeficiency virus (HIV). The nurse has provided instructions to the client regarding ways to maximize absorption of the medication. Which of the following, if stated by the client, indicates an adequate understanding of the use of this medication? 1. "I need to take the medication with my large meal of the day." 2. "I need to store the medication in the refrigerator." 3. "I need to take the medication with water but on an empty stomach." 4. "I need to take the medication with a high-fat snack."

3. "I need to take the medication with water but on an empty stomach." Rationale: To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar. It is not to be administered with a large meal. The medication should be stored at room temperature and protected from moisture because moisture can degrade the medication.

A nurse is assisting in developing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention should the nurse suggest including in the plan of care to manage this symptom? 1. Keep the call bell within reach for the client. 2. Administer a sedative at bedtime. 3. Administer an antipyretic at bedtime. 4. Provide a back rub and comfort measures before bedtime.

3. Administer an antipyretic at bedtime. Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 2, and 4 are important interventions but they are unrelated to the subject of fever and night sweats.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions on the skin

3. Punch biopsy of the cutaneous lesions Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB) asks the nurse how long the medication therapy lasts. The nurse responds that the duration of therapy would likely be for at least: 1. 6 total months and at least 1 month after cultures convert to negative 2. 6 total months and at least 3 months after cultures convert to negative 3. 9 total months and at least 3 months after cultures convert to negative 4. 9 total months and at least 6 months after cultures convert to negative

4. 9 total months and at least 6 months after cultures convert to negative Rationale: The client with tuberculosis who is coinfected with HIV requires that antitubercular therapy last longer than usual. The prescription is usually for a total of 9 months and at least 6 months after sputum cultures convert to negative.

A nurse is assisting in preparing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure should the nurse include in the plan? 1. Dairy products with each snack and meal 2. Red meat daily 3. Adding spices to food to make the taste more palatable 4. Foods that are at room temperature

4. Foods that are at room temperature Rationale: The client with AIDS experiencing nausea should avoid fatty products, such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided because they aggravate nausea. Foods are best tolerated either cold or at room temperature.

A client who is human immunodeficiency virus (HIV) positive has had a Mantoux skin test. The results show a 7-mm area of induration. The nurse evaluates that this result is: 1. Negative 2. Borderline 3. Uncertain 4. Positive

4. Positive Rationale: The client with HIV is considered to have positive results on Mantoux skin testing with an area of 5 mm of induration or greater. The client without HIV is positive with induration greater than 10 or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is also possible for the client infected with HIV to have false negative readings because of the immunosuppression factor.

A client with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalized to increase intake of foods such as: 1. Raw fruits and vegetables 2. Hot soup 3. Peanut butter 4. Puddings

4. Puddings Rationale: The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply. 1. Use non-latex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure

Answer: 1 2 4 5 Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use non-latex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with a rubber stopper that requires puncture with a needle. It is not necessary to place the client in a private room.

To be diagnosed as having AIDS, the patient must be HIV-positive, have a compromised immune system without known immune system disease or recent organ transplant, and present with which of the following?

CD4+ lymphocyte count less than 200 mm3

A male patient is concerned about telling others he has HIV infection. What should the nurse stress when discussing his concerns?

Care providers and sexual partners should be told about his diagnosis.

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What should the nurse look for when reviewing a patient's chart to determine whether she has progressed from HIV disease to AIDS?

HIV-positive test result, CD4+ count below 200, history of opportunistic disease

Which of the following is a CDC criterion for the progression of HIV infection to AIDS?

Increase in viral load

The nurse explains to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is made based on:

Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests

The nurse should instruct the patient who is diagnosed with AIDS to report signs of Kaposi sarcoma, which include:

Reddish-purple skin lesions

While teaching community groups about AIDS, what should the nurse indicate as the most common method of transmission of the HIV virus?

Sexual contact with an HIV-infected partner

The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes. What should the nurse counsel this patient about?

Sexual history, risk reduction measures, and testing for HIV

A male patient is advised to receive HIV antibody testing because of his multiple sexual partners and injectable drug use. What should the nurse inform the patient to ensure understanding?

The blood is tested with an ELISA; if positive, it is tested again with an ELISA, followed by a Western blot if the second ELISA is positive.

Why should interventions such as promotion of nutrition, exercise, and stress reduction be undertaken by the nurse for patients who have HIV infection?

They will improve immune function.

A 21-year-old male who has been an IV heroin user has been experiencing fever, weight loss, and diarrhea and has been diagnosed as having AIDS. At this time, he has a low-grade fever, severe diarrhea, and a productive cough. He is admitted with Pneumocystis jiroveci. What should the nurse do when caring for the patient?

Use a gown, mask, and gloves when assisting the patient with his bath

The HIV patient asks the nurse about what to expect in terms of disease progression. The nurse tells this patient that although the disease can vary greatly among individuals, the usual pattern of progression includes:

acute retroviral syndrome, early infection, early symptomatic disease, and AIDS.

Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma? 1. A kidney transplant client 2. A male with a history of same-sex partners 3. A client receiving antineoplastic medications 4. An individual working in an environment where exposure to asbestos exists

an individual working in an environment where exposure to asbestos exists rationale Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common AIDS indicator. it is seen frequently in men with a history of same-sex partners. although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. the renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. exposure to asbestos is not related to the development of Kaposi's sarcoma.

Which of the following are early signs and symptoms of an HIV infection? (Select all that apply.)

b. Weight loss c. Sore throat f. Dyspnea ANS: B, C, F

For most people who are HIV-positive, marker antibodies are usually present 10 to 12 weeks after exposure. What is the development of these antibodies called?

seroconversion