med/surg chapter 21

The nurse is completing a health history for a client and begins to obtain a sexual history. What is the nurse's best opening question?

"How do you feel about answering questions about your sexual history?"

The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed?

"I will be sure to eat lots of fresh fruits and vegetables every day."

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?

"I will let my sister clean my pet iguana's cage from now on."

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?

"I will store my condoms in my wallet so they are always handy."

The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a student indicates that additional teaching is required?

"I won't get HIV if I only have oral sex with my partner."

The nurse asks a young adult client if she is sexually active. The client asks why the nurse needs to know. What is the nurse's best response?

"If you are sexually active, we should talk about ways to prevent getting HIV."

An HIV-positive client verbalizes concerns about the high cost of antiretroviral medications. What is the nurse's best response?

"Let's talk to the social worker about getting financial assistance for you."

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?

"Rinse used needles and syringes with water followed by laundry bleach after using them."

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?

"Rotate the sites where you will be giving the injections."

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 nurse's questions. What is the nurse's best response?

"Take your time. I realize that this is a very private topic to talk about."

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 nurse's best response?

"The HAART medications are working well right now."

A nursing assistant asks the nurse if respiratory isolation is needed for a client with Pneumocystis jiroveci pneumonia. What is the nurse's best response?

"This type of pneumonia is an opportunistic infection, so the staff is not at risk."

The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The client states, "I'm an old woman! I cannot possibly get HIV." What is the nurse's best response?

"Women in your age-group are the fastest growing population of AIDS clients today."

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?

"You should work phone triage at the desk today rather than taking clients."

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 nurse's best response?

"Your count is a bit low and you are susceptible to infection."

The nurse is caring for a client who is HIV positive. The client has become confused over the course of the shift, and the client's pupils are no longer reacting to light equally. The nurse anticipates an order for which medication?

Prednisone (Deltazone)

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?

ANS: 420 185 lb 1 kg/2.2 lb 5 mg/kg = 420 mg/dose

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

ANS: 6 198 lb 1 kg/2.2 10 mg/kg = 900 mg 1 capsule/150 mg = 6 capsules/day

The nurse is seeing clients at a drop-in primary health clinic. Which client does the nurse teach about the risks of acquiring HIV?

All clients who come to the clinic

Which action by the nurse is most effective to prevent becoming exposed to the human immune deficiency virus (HIV)?

Always use Standard Precautions with all clients in the workplace.

A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first?

Ask the client to place his chin on his chest.

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?

Call the physician to clarify the order.

The nurse is caring for a client with HIV who has been prescribed didanosine (Videx EC). Which action by the nurse is most appropriate?

Help the client plan specific meal and dosing times.

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?

Initiate seizure precautions with padded siderails.

An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate?

Liver enzymes

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?

Make sure that a clock and a calendar are easily visible.

A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The client's purified protein derivative (PPD) test, placed 3 days ago in the clinic, is negative. Which action by the nurse is most appropriate?

Place the client in Airborne Precautions

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.)

Provide an incentive spirometer to encourage coughing and deep breathing by the client. Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only. Request that the family take home the fresh flowers that are at the client's bedside. Assist the client with meticulous oral care after meals and at bedtime.

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 nurse's face. Which drug regimen does the nurse prepare to initiate?

Retrovir (zidovudine) and Epivir (lamivudine) for 28 days

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?

Six vaginal yeast infections in the last 12 months

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?

Take the client's medications to radiology and administer them there if possible.

The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in confirming progression of the client's diagnosis to AIDS?

Thick white patches on the client's tongue