NUR 202 Module D Practice

A client with acquired immunodeficiency syndrome gets recurrent Candida infections of the mouth (thrush). The nurse has given the client instructions to minimize the occurrence of thrush and determines that the client understands the instructions if which statement is made by the client?

* I should use warm saline or water to rinse my mouth* - When a client is in a state of immunosuppression or has decreased levels of some normal oral flora, an overgrowth of the normal flora Candida can occur. Careful routine mouth care is helpful to prevent the recurrence of Candida infections. The client should use a mouthwash that consists of warm saline or water. Red meat will not prevent thrush. The timeframes given for oral hygiene in options B and C are too infrequent.

A 6-year-old child with human immunodeficiency virus (HIV) who has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child?

*"I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less."* Rationale: The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. The nurse must acknowledge the child's pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof would eliminate the pain is inaccurate. Allowing a child to think that he or she can control the pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken "all away" is neither truthful nor realistic.

A home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction?

*"I will clean up any spills from the diaper with diluted alcohol."* -Rationale: HIV is transmitted through blood, semen, vaginal secretions, and breast milk. The mother of an infant with HIV should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child's diaper. Alcohol would not be effective in destroying the virus. Options B, C, and D are accurate instructions related to basic infection control.

A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide?

*"Take ferrous sulfate and the antacid at least 2 hours apart."*- The nurse should instruct the client to take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.

A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [Retrovir]), 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?

*"Take zidovudine every 4 hours around the clock."*- To be effective, zidovudine must be taken every 4 hours around the clock. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the physician before taking OTC medications.

The nurse is preparing to administer a unit of blood to a client who's anemic. After its removal from the refrigerator, the blood should be administered within:

*4 hours*- After the blood is removed from the refrigerator, it must be administered within 4 hours. Refrigeration delays the growth of bacteria in the blood. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload .

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?

*Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.*- To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) has a T4 count of 150/mm3, and a T4:T8 ratio that is less than 2. The nurse interprets from these laboratory values that the client is:

*At risk for opportunistic infection* - A T4 cell count that is less than 200/mm3 and a T4:T8 ratio of less than 2 indicates that the client is exhibiting immunological manifestations of the disease and is at risk for opportunistic infection. The nurse uses this information in planning prevention control measures for the client. Therefore, options A, B, and C are incorrect. Additionally, these laboratory tests do not determine a client's nutrition status

The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should plan care with the understanding that which childhood psychosocial need occurs at this age?

*Beginning to conceptualize the death process as involving physical harm* - Rationale: A preschool child begins to conceptualize the death process as involving physical harm. A child from birth to 2 years of age is unable to grasp the concept of illness and death. A school-age child begins to understand that something is wrong. An adolescent expresses fear, withdrawal, and denial.

The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction?

*Bronchospasm*- Hypersensitivity reactions to antiplatelet drugs, particularly anaphylaxis, can occur; the most common is the induction of bronchospasm with asthmalike symptoms. Difficulty hearing and confusion are adverse reactions associated with aspirin only. Agranulocytosis is associated with sulfinpyrazone.

Which laboratory test value is elevated in clients who smoke and can't be used as a general indicator of cancer?

*Carcinoembryonic antigen level*- In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer.

The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:

*Fat* - A diet containing excessive fat seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues. Immune dysfunction has been linked to deficient — not excessive — intake of protein, vitamin A, and zinc.

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

*Following safer sex practices* - It's essential that clients with AIDS follow safer-sex practices to prevent transmission of the human immunodeficiency virus (HIV). Although it's helpful if clients with AIDS avoid using recreational drugs and alcohol, it's more important that I.V. drug users use clean needles and dispose of used needles for purposes of avoiding transmission. Whether the client with AIDS chooses to tell anyone about the diagnosis is his decision; there is no legal obligation to do so.

A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?

*Listen and show interest, as the client expresses their feelings*- The nurse should listen actively and nonjudgmentally as the client expresses feelings. Telling the client not to worry would provide false reassurance. A psychiatric consultation would be appropriate only after further assessment. Stating that the client's friends aren't true friends would discount the client's feelings.

The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

*Monitor body temperature* - Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation.

Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)?

*Monitor the child's weight, Frequent hand-washing is important, The child should avoid exposure to other illnesses, and Clean up body fluid spills with bleach solution (10: 1 ratio of water to bleach).* - Rationale: AIDS is a disorder caused by HIV and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand-washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, and diarrhea and notifying the health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; monitoring weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding sharing eating utensils. Gloves are worn for care, especially when in contact with body fluids and changing diapers; diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with the tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10: 1 ratio of water to bleach).

A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?

*Osteoporosis*- All of the options listed above are adverse effects of long-term corticosteroid therapy; however, osteoporosis frequently causes compression fractures of the spine. The other adverse effects aren't likely to cause severe back pain.

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?

*Reduced sneezing*- Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, the client shouldn't experience increased salivation or tearing. Because decongestants alleviate congestion, they also relieve headaches, which may be caused by congestion.

The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

*Urine output of 20 ml/hr*- Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. The other options are normal assessment findings

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:

*Wear gloves when providing mouth care* - Standard precautions stipulate that a health care worker wear gloves when contact with any client's blood or body fluids is anticipated, such as when providing mouth care. Maintaining strict isolation isn't needed because human immunodeficiency virus is spread by contact with contaminated blood or body fluids, which can be avoided by following standard precautions. A private room wouldn't provide barrier protection, which is needed for standard precautions. Wearing a gown is appropriate only when anticipating splashing of blood or body fluids

A nurse is developing a plan of care for the client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention would the nurse include in the plan of care to manage these symptoms?

*administer an antipyretic at bedtime* - For clients with AIDS who experience night fever and night sweats, it is useful to offer the client an antipyretic before bedtime. It is also helpful to keep a change of bed linens and nightclothes 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 A, B, and D are important interventions, but they are unrelated to the subject of fever and night sweats.

A client with acquired immunodeficiency syndrome is being treated for tuberculosis with isoniazid (INH). The nurse plans to teach the client which of the following regarding the administration of the medication?

*administer it at least 1 hour before administering an aluminum-containing antacid to prevent a medication interaction* - Aluminum hydroxide, which is a common ingredient in antacids, significantly decreases INH absorption. INH should be administered at least 1 hour before aluminum-containing antacids. Food affects the rate of absorption of rifampin (Rifadin) rather than INH. INH administration with a corticosteroid decreases INH's effects and increases the effects of the corticosteroid.

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse prepares to implement which prescribed measure as the most effective means to treat the problem?

*administer prescribed antibiotics* - The most effective way to treat an acid-base disorder is to treat the underlying cause of the disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client to rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.

A male adult calls the emergency department and tells the nurse that he received a bee sting to the arm while weeding a garden. The client states that he has received bee stings in the past and is not allergic to bees. The client states that the site is painful and asks the nurse for advice to alleviate the pain. Then nurse tells the client to first:

*apply ice and elevate the site* - When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain can be alleviated by applying an ice pack and elevating the site. A heating pad will increase discomfort at the site. The client can take acetaminophen to assist in alleviating discomfort, but this would not treat the injury at a local level. Lying down and elevating the arm may have some effect on reducing edema at the site but will not directly assist in alleviating the pain at the site of injury.

A home care nurse visits a client who has recently been told that she is positive for human immunodeficiency virus (HIV). The client is having difficulty accepting the diagnosis. The home care nurse analyzes the client's behavior and should:

*assess the client's coping skills and knowledge deficit regarding HIV * - The diagnosis of HIV is difficult to accept. Clients can exhibit a variety of reactions that are not necessarily a direct result of ineffective coping skills. The nurse must also know that persons with HIV are living well beyond 1 year. Ignoring the problem will not eliminate the client's difficulty in understanding the disease process. The nurse must focus on the knowledge deficit of a disease process and other psychosocial interventions.

A nurse is reviewing the medical record of a young female client who is suspected off having systemic lupus erythematosus (SLE). Which of the following would the nurse expect to note documented in the record that is related to this diagnosis?

*butterfly rash on cheeks, and the bridge of nose* - SLE occurs primarily in females 10 to 35 years of age, and is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE. Option A is found in sickle cell anemia. Options B and C are found in many conditions, but are not usually noted in SLE.

A client with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse suggests to the client that swallowing may be easier if which of these foods are eaten?

*cooked macaroni and spaghetti dishes* - 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.

A nurse caring for a client with acquired immunodeficiency syndrome (AIDS) is monitoring the client for signs of complications. The earliest assessment finding that would indicate the presence of Pneumocystis jiroveci is which of the following?

*cough* - As the first symptom, the client with P. jiroveci infection usually has a cough that begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

A client with acquired immunodeficiency syndrome has a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements. The nurse has instructed the client regarding methods of maintaining and increasing weight. The nurse determines that the client would benefit from further instruction if the client stated the need to:

*eat low-calorie snacks between meals* - The client should eat small, frequent meals throughout the day. The client also should take in nutrient-dense and high-calorie meals and snacks. The client is encouraged to eat favorite foods to keep intake up and to plan meals that are easy to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety occurs.

A nurse is preparing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure would the nurse include in the plan?

*foods that are at a cool temperature* - The AIDS client 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.

The nurse is preparing to nasotracheally suction a client with acquired immunodeficiency syndrome (AIDS) who has had blood-tinged sputum with previous suctioning. The nurse plans to use which of the following items as part of standard precautions for this client?

*gloves, mask, and protective eyewear* - Standard precautions include the use of gloves whenever there is actual or potential contact with blood or body fluids. During procedures that aerosolize blood, the nurse wears a mask and protective eyewear or a face shield. Impervious gowns are worn in those instances when it is anticipated that there will be contact with a large amount of blood.

The nurse is admitting a client with a diagnosis of acquired immunodeficiency syndrome (AIDS) to the medical-surgical unit. The nurse most importantly assesses for which of the following?

*jaundiced skin* - Clients with AIDS frequently develop opportunistic infections. Candida albicans, the causative organism of thrush, is a common opportunistic infection. Thrush presents as white patches in the oral cavity. Hairy leukoplakia also presents as white patches in the oral cavity. Clients with AIDS frequently acquire pneumonia and may present with tachypnea, not bradypnea. Jaundice is a symptom of hepatic disease. Clients with AIDS frequently have inadequate nutrition and hydration and may present with dehydration, resulting in a high specific gravity rather than a low specific gravity.

The nurse has an order to administer foscarnet sodium (Foscavir) intravenously to a client with acquired immunodeficiency syndrome (AIDS). Before administering this medication, the nurse plans to:

*place the solution on a controlled infusion pump* - Foscarnet sodium is an antiviral agent used to treat cytomegalovirus (CMV) retinitis in clients with AIDS. Because of the potential toxicity of the medication, it is administered with the use of a controlled infusion device. A sputum culture is not necessary. Folic acid is not an antidote. It is highly toxic to the kidneys, and serum creatinine levels are measured frequently during therapy.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who ask for a snack. Which of the following would be appropriate choice for this client to meet nutritional needs?

*poached pears* - Nursing care to meet the nutritional needs of clients with AIDS centers around nursing interventions to provide protection from infection. The main considerations to be remembered include avoiding all milk or milk products, and completely cooking all meals, especially raw vegetables and fruits prior to eating. Remember that these clients are immunocompromised. Foods that have the potential to harbor bacteria need to be avoided.

A client with acquired immunodeficiency syndrome (AIDS) who has cytomegalovirus (CMV) retinitis is receiving ganciclovir (Cytovene). The nurse would plan to do which of the following while the client is taking this medication?

*provide the client with a soft toothbrush and an electric razor* - Ganciclovir causes neutropenia and thrombocytopenia as the frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding, and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. Venipuncture sites should be held for approximately 10 minutes. The medication does not have to be taken on an empty stomach. The medication may cause hypoglycemia but not hyperglycemia

A client with acquired immunodeficiency syndrome (AIDS) has difficulty in swallowing and the nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client states that he or she should increase intake of foods such as:

*pudding* - The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client is also 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.

The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid foodborne illnesses. The nurse instructs the client to prevent acquiring infection from food by avoiding which of the following items?

*raw oysters* - The client is taught to avoid raw or undercooked seafood, meat, poultry, and eggs. The client should also avoid unpasteurized milk and dairy products. Fruits that can be peeled, as well as bottled beverages, are safe. The client may be taught to avoid sorbitol, but this is to diminish diarrhea and has nothing to do with foodborne infections.

A nurse is admitting a client with a diagnosis of acquired immunodeficiency syndrome (AIDS) to the hospital. The nurse reviews the client's record and notes that the admitting physician has documented that the client has recently developed Kaposi's sarcoma. Which finding would the nurse expect to note on admission of the client?

*reddish blue lesions on the skin* - 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, then to the face and oral mucosa. They can spread to the lymphatic system, lungs, and gastrointestinal (GI) 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 GI lesions.

A client has tested positive for human immunodeficiency virus (HIV) antibody. The CD4+ T-cell count is 0.190 mg/L. The nurse formulates which appropriate nursing diagnosis for this client?

*risk for infection related to immunodeficiency* - Clients who test positive for HIV antibody are at risk for opportunistic infection. The normal CD4+ T-cell count is between 500 and 1600 mcg/L. As the CD4+ T-cell count falls, the client's risk for infection increases. Clients with HIV infection or acquired immunodeficiency syndrome are commonly afflicted with diarrhea, not constipation. Options B, C, and D are incorrect because they do not relate to the data in the question.

The nurse has been assigned to care for a young man recovering at home from a disabling lung infection. While obtaining a nursing history, the nurse learns that infection. While obtaining a nursing history, the nurse learns that the infection is probably the result of human immunodeficiency virus (HIV). The nurse informs the client that she is morally opposed to homosexuality and cannot care for him. The nurse then leaves the client's home. Which of the following is true regarding the nurse's actions?

*the nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner* - The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy does not apply if it interferes with the rights of the client. There is no legal obligation to inform the client of the nurse's personal objections to the client. Refusal to provide care may be acceptable if that refusal does not put the client's safety at risk and the refusal is primarily associated with religious objections, not personal objection to lifestyle or medical diagnosis. The nurse also has an obligation to observe the principle of nonmaleficence (neither causing nor allowing harm to befall the client).

A client with acquired immunodeficiency syndrome (AIDS) will be receiving aerosolized pentamidine isethionate (NebuPent) prophylactically once every 4 weeks. The home health nurse visits and instructs the client about the medication. Which statement by the client indicates a need for further teaching?

*there are no known side effects of this therapy* - Side effects associated with this aerosolized therapy include nausea, visual disturbances, and shortness of breath. The client needs to inform the health care provider if these side effects occur.

A client is being tested to human immunodeficiency virus (HIV); the results of two enzyme-linked immunosorbent assay (ELISA) tests have been positive. The nurse anticipates that which of the following diagnostic tests will be prescribed next?

*western blot* - If the results of two ELISA tests are positive, the Western blot is done to confirm the findings. If the result of the Western blot is positive, then the client is considered to be positive for HIV and infected with the HIV virus. The CD4 count identifies the T-helper lymphocyte count and is performed to determine progression and treatment. A bone marrow biopsy is not a component of the diagnostic studies for HIV.

Testing for HIV, after exposure would include:

Initial test (that week), and then one at 6 months. Q1yr after that. Antibodies are being made, usually 3 wks to 3 mos. after contact.