Lewis Chapter 15 - n2

1. When caring for a patient who has just been diagnosed with early chronic HIV infection, which prophylactic measures will the nurse anticipate being included 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. Hepatitis B vaccine B. Pneumococcal vaccine C. Influenza virus vaccine 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 count has dropped or when infection has occurred.

6. When the nurse is caring for a patient whose HIV status in unknown, which of these patient exposures is most likely to require postexposure prophylaxis? 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. Needle stick with a needle and shrine used to draw blood 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 patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

11. The nurse is reviewing the chart for a patient who is scheduled for an annual physical exam. Which information will be most important in determining whether the patient needs HIV testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation

A. Patient age The current 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.

12. A 24-year-old woman who uses injectable illegal drugs asks the nurse about preventing AIDS. The nurse informs the patient that the best way to reduce the risk of HIV infection from drug use is to a. participate in a needle-exchange program. b. clean drug injection equipment before use. c. ask those who share equipment to be tested for HIV. d. avoid sexual intercourse when using injectable drugs.

A. participate in a needle-exchange program Participation in needle-exchange programs has been shown to control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced by individuals in withdrawal. 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.

1. A patient who has vague symptoms of fatigue and headaches is found to have a positive enzyme immunoassay (EIA) for human immunodeficiency virus (HIV) antibodies. In discussing the test results with the patient, the nurse informs the patient that a. the EIA test will need to be repeated to verify the results. b. a viral culture will be done to determine the progress of the disease. c. it will probably be 10 or more years before the patient develops acquired immunodeficiency syndrome (AIDS). d. the Western blot test will be done to determine whether AIDS has developed.

A. the EIA test will need to be repeated to verify the results 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 part of HIV testing. Because the nurse does not know how recently the patient was infected, it is not appropriate to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.

17. To evaluate the effectiveness of ART, the nurse will schedule the patient for a. viral load testing. b. enzyme immunoassay. c. rapid HIV antibody testing. d. immunofluorescence assay.

A. viral load testing 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.

5. A pregnant woman with a history of early chronic HIV infection is seen at the clinic. 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. Since 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 drug therapy (ART).

B. Most infants born to HIV-positive mothers are not infected with the virus 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.

16. The nurse is preparing to give the following medications to an HIV-positive patient who is hospitalized with Pneumocystis jiroveci pneumonia (PCP). Which is most important to administer at the right time? a. Nystatin (Mycostatin) tablet for vaginal candidiasis b. Oral saquinavir (Inverase) to suppress HIV infection c. Aerosolized pentamidine (NebuPent) for PCP infection d. Oral acyclovir (Zovirax) to treat systemic herpes simplex

B. Oral saquinavir (Inverase) to suppress HIV infection 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.

20. Which action can the nurse delegate to nursing assistive personnel (NAP) who help with the care of a patient admitted with tuberculosis and placed on airborne precautions? a. Teach the patient about how to use tissues to dispose of respiratory secretions. b. Stock the patient's 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 patient's family members the reason for the use of airborne precautions.

B. Stock the patient's room with all the necessary personal protective equipment Since all health care workers will be educated about the various types of infection precautions used in the hospital, the NAP can safely stock the room with personal protective equipment. Obtaining contact information and patient education are higher-level skills that require RN education and scope of practice.

21. When designing a program to decrease the incidence of HIV infection in the community, the nurse will prioritize teaching about a. methods to prevent perinatal HIV transmission. b. how to prevent transmission between sexual partners. c. ways to sterilize needles used by injectable drug users. d. means to prevent transmission through blood transfusions.

B. how to prevent transmission between sexual partners Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide education about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

19. Ten years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and an undetectable viral load. What is the priority nursing intervention at this time? a. Monitor for symptoms of AIDS. b. Teach about the effects of antiretroviral agents. c. Encourage adequate nutrition, exercise, and sleep. d. Discuss likelihood of increased opportunistic infections.

C. Encourage adequate nutrition, exercise, and sleep The CD4+ level for this patient is in the normal range, indicating that the patient is the early chronic stage of 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 initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

10. When assessing an individual who has been diagnosed with early chronic HIV infection and has a normal CD4+ count, the nurse will a. check neurologic orientation. b. ask about problems with diarrhea. c. palpate the regional lymph nodes. d. examine the oral mucosa for lesions.

C. palpate the regional lymph nodes Persistent generalized lymphadenopathy is common in the early stage of chronic infection. Diarrhea, oral lesions, and neurologic abnormalities would occur in the later stages of HIV infection.

3. After having a positive rapid-antibody test for HIV, a patient is anxious and does not appear to hear what the nurse is saying. At this time, it is most important that the nurse 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. remind the patient about the need to return for retesting to verify the results 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.

4. A patient who is diagnosed with AIDS tells the nurse, "I have lots of 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. "Can you tell me more about the kind of thoughts you are having?" More assessment of the patient's 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 nurse's ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patient's feelings.

9. Which of these patients will the nurse working in an HIV testing and treatment clinic anticipate teaching about antiretroviral therapy (ART)? a. A patient who is currently HIV negative but has unprotected sex with multiple partners b. A patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µl c. An HIV-positive patient with a CD4+ count of 120/µl who drinks a fifth of whiskey daily d. A patient who tested positive for HIV 2 years ago and has cytomegalovirus (CMV) retinitis

D. A patient who tested positive for HIV 2 years ago and has cytomegalovirus (CMV) retinitis CMV retinitis is an 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.

13. Which nursing action will be most useful in assisting a 21-year-old 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 patient's class schedule to help decide when the ART should be taken.

D. Check the patient's class schedule to help decide when the ART should be taken The best approach to improve adherence is to learn about important activities in the patient's 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 patient's schedule.

8. Antiretroviral therapy (ART) is being considered for an HIV-infected patient who has a CD4+ cell count of 400/µl. Which factor is most important to consider when determining whether ART will be started for this patient? a. Patient social support system b. HIV genotype and phenotype c. Potential medication side effects d. Patient ability to comply with ART schedule

D. Patient ability to comply with ART schedule Drug resistance develops quickly unless the patient takes ART medications on a stringent schedule, and this 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.

7. A 20-year-old female patient who is HIV-positive has a new prescription for efavirenz (Sustiva). Which information about the patient is most important to communicate to the prescribing physician before administering the efavirenz? a. The patient's CD4+ T cell count is 800 cells/μL. b. The patient already has etravirine (Intelence) prescribed. c. The patient states that the antiretroviral therapy (ART) frequently cause nausea. d. The patient is sexually active and does not use any contraception.

D. The patient is sexually active and does not use any contraception Efavirenz can cause fetal anomalies and should not be used in patients who may be pregnant. The patient's nausea, use of another nucleoside reverse transcriptase inhibitor, and CD4+ count also should be communicated to the physician, but the most important information is that the patient may potentially be pregnant.

18. Which information about an HIV-positive patient who is taking antiretroviral medications is most important for the nurse to address when planning care? a. The patient's blood glucose level is 168 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. The patient states "Sometimes I miss a dose of zidovudine (AZT)." Since 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.

15. A patient who has been treated for HIV infection for 7 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. The nurse will anticipate teaching the patient about a. the benefits of daily exercise. b. foods that are higher in protein. c. treatment with antifungal agents. d. a change in antiretroviral therapy.

D. a change in antiretroviral therapy A frequent first intervention for metabolic disorders is a change in 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.

2. A patient is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and HIV testing is positive. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), the patient is diagnosed as having a. acute infection. b. early chronic infection. c. intermediate chronic infection. d. late chronic infection or AIDS.

D. late chronic infection or AIDS Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other responses indicate an earlier stage of HIV infection than is indicated by the PCP infection.

14. A patient with HIV infection has developed Mycobacterium avium complex infection. An appropriate outcome for the patient is that the patient will a. be free from injury. b. receive immunizations. c. have adequate oxygenation. d. maintain intact perineal skin.

D. maintain intact perineal skin 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.