Ch. 16 & 17
The client who wants to use Truvada for preexposure prophylaxis (PreP) asks the nurse why testing is needed for HIV status before starting this drug. How does the nurse respond? "The side effects of this drug are worse if you have a detectable HIV viral load." "If you take this drug and are HIV positive, your risk for co-infection with the hepatitis B virus is increased." "Although this drug can help prevent HIV infection, it is not enough by itself to control "the disease if you are HIV positive." Some people have a genetic mutation that increases the risk for life-threatening reactions "while taking this drug if they are also HIV positive."
"Although this drug can help prevent HIV infection, it is not enough by itself to control "the disease if you are HIV positive."
Which statement made by the nurse during an admission assessment for a client who is HIV positive demonstrates a nonjudgmental approach in discussing sexual practices and behaviors? "Have you had sex with men or women or both?" "I hope you use condoms to protect your partners." "You must tell me all of your partners' names, so I can let them know about possibly being infected." "You don't participate in anal intercourse, do you?"
"Have you had sex with men or women or both?"
Which statement made to the nurse by an assistive personnel (AP) assigned to care for an HIV-positive client indicates a breach of confidentiality and requires further education by the nurse? "I told family members they need to wash their hands when they enter and leave the room." "The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client." "Yes, I understand the reasons why I have don't need to wear gloves when I feed the client." "The client's spouse told me she got HIV from a blood transfusion."
"The other assistive personnel and I were out in the hallway discussing our concern about getting HIV from our client."
Which point is most important for the nurse to include when teaching assistive personnel (AP) about protecting themselves from HIV exposure when caring for HIV-positive clients? "Wear gloves when in contact with clients' mucous membranes or nonintact skin." "Wear full protective gear when providing any care to HIV-positive clients." "Always wear a mask when entering an HIV-positive client's room." "Talk to the employee health nurse about starting preexposure prophylaxis."
"Wear gloves when in contact with clients' mucous membranes or nonintact skin."
What is the nurse's best response to a 38-year-old client with a large wound who does not want to receive a tetanus toxoid vaccination because he had a tetanus shot just 1 year ago? "Tetanus is a more serious disease and a "booster" is required every year to ensure adequate immunity and protection against it." "Because antibody production slows down as you age, it is better to take this vaccination as a booster to the one you had a year ago." "You may not need this vaccination now, I will check with your health care provider." "You need this vaccination because the strain of tetanus changes every year."
"You may not need this vaccination now, I will check with your health care provider." When people have been "boosting" their tetanus antibodies on a regularly scheduled basis, they should have sufficient circulating antibodies to mount a defense against exposure to tetanus. If this client's medical records substantiate that he did indeed receive a tetanus toxoid booster 1 year ago, he does not need another one now.
What is the most important precaution for the nurse to teach a client who has few natural killer cells and the natural killer cells are not very active? "You will no longer develop a fever when you have an infection, so you must learn to identify other symptoms of infection." "You will be at an increased risk for developing allergies, so it will be necessary for you to avoid common allergens." "You will need to avoid people with viral infections because it is harder now for you to develop antibodies." "You will need to have yearly checkups because your risk for cancer development is greater now."
"You will need to avoid people with viral infections because it is harder now for you to develop antibodies." Natural killer cells provide protection against development of cancer by recognizing unhealthy or cancer cells as non-self and taking action to destroy them.
A clinic nurse is working with an older client. What action is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes
A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.
An HIV-negative client who has an HIV-positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug? a. Does not reduce the need for safe sex practices. b. Has been taken off the market due to increases in cancer. c. Reduces the number of HIV tests you will need. d. Is only used for postexposure prophylaxis.
A Tenofovir/emtricitabine is a newer drug used for preexposure 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.
A client with HIV-II 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 and food. The nurse would consult with a pharmacist about possible interactions. Client teaching is important but does not take precedence over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.
A primary health care provider notifies the nurse that a client has a "bandemia." What action does the nurse anticipate? a. Administer antibiotics. b. Place the client in isolation. c. Administer IV leukocytes. d. Obtain an immunization history.
ANS: A A bandemia, or shift to the left, in the white count differential means that an acute, continuing infection has placed so much stress on the immune system that the most numerous type of neutrophil in circulation are immature, or band cells. The nurse would anticipate administering antibiotics. The client may or may not need isolation. Leukocyte infusion and immunization history are not relevant.
A nurse learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils
ANS: A The B-cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B-cells.
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV). 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 client's 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.
ANS: 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 21 days. The confirmatory Western Blot test takes an additional 7 days, so using that testing algorithm, the client's status may not truly be known for up to 28 days. The client may have had exposure that has not yet been confirmed. The nurse needs to assess the client's sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate. Testing would be recommended every 3 months for someone engaging in high risk behaviors.
A client has been hospitalized with an opportunistic infection secondary to HIV-III. The client's partner is listed as the emergency contact, but the client's 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.
ANS: A The client should make his or her wishes known and formalize them through advance directives. The nurse would 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, but the nurse would be the client's advocate and help ensure his or her wishes are met.
The nurse is caring for a client diagnosed with HIV-II. The client's CD4+ cell count is 399/mm3 (0.399 × 109/L). 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.
ANS: A This client is in the Centers for Disease Control and Prevention HIV-II case definition group. He or she remains highly infectious and would be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required, although some medications may need to be taken while abstaining. 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 precedence over stopping the spread of the disease.
A client has just been informed of a positive HIV test. 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.
ANS: A This client needs the assistance of support systems. The nurse would 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. Positive HIV test results are reportable in all 50 states, Washington, D.C., and Canada but the nurse works with the client to support his or her choices in disclosure. The nurse would not tell the family for the client.
For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells
ANS: A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.
The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.) a. Higher risk for respiratory tract and genitourinary infections. b. May not have a fever with severe infection. c. Show expected changes in white blood cell counts. d. Should receive influenza, pneumococcal, and shingles vaccinations. e. Skin tests for tuberculosis may be falsely negative. f. Booster vaccinations are not likely needed as one ages.
ANS: A, B, D, E Immunity changes during an adult's life and older adults have decreased immune function. The number and function of neutrophils and macrophages are reduced leading to reduced response to infection and injury, such as temperature elevation. The usual response of an increased white blood cell count is delayed or absent. Older adults are less able to make new antibodies in response to the presence of new antigens requiring repeat vaccinations and immunizations. Skin tests for tuberculosis may be falsely negative and there is an increased risk for bacterial and fungal infections due to the decreased number of circulating T-lymphocytes.
The nurse learns that which risk factors can affect immunity? (Select all that apply.) a. Age b. Environmental factors c. Ethnicity d. Drugs e. Nutritional status
ANS: A, B, D, E Immunity changes during an adult's life as a result of nutritional status, environmental conditions, drugs, disease, and age. Immunity is most efficient in young adults and older adults have decreased immune function. Ethnicity does not affect immunity.
The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low. What information does the nurse provide? (Select all that apply.) a. Do not work in the garden or with houseplants. b. Do not empty the kitty litter boxes. c. Clean your toothbrush in the dishwasher daily. d. Bathe daily using antimicrobial soap. e. Avoid people who are sick and large crowds. f. Make sure meat, fish, and eggs are cooked well.
ANS: A, B, D, E, F Ways to avoid infection when immunocompromised include not working in the garden or with houseplants; not emptying litter boxes; running the toothbrush through the dishwasher at least weekly; bathing daily using antimicrobial soap; avoiding sick people and large crowds; and making sure meat, fish, and eggs are cooked well prior to eating them.
Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 (0.2 × 109/L) or less than 14% b. Infection with P. 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 f. Confusion, dementia, or memory loss
ANS: A, B, D, F 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 (0.2 × 109/L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as P. jiroveci and HIV wasting syndrome. Confusion, dementia, and memory loss are central nervous system indications. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.
The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth f. Decreased function
ANS: A, D, E, F The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.
A client with HIV-II has had a sudden decline in status with a large increase in viral load. What action would 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.
ANS: 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 to be effective. Since this client's viral load has increased dramatically, the nurse would first assess this factor. After this, the other assessments may or may not be needed.
A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most important with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic exam
ANS: B Cryptosporidiosis can cause diarrhea and wasting with extreme loss of fluids and electrolytes. The nurse would assess signs of hydration/dehydration as the priority, including checking the client's mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.
A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Conduct frequent neurologic assessments. c. Conduct frequent respiratory assessments. d. Initiate Protective Precautions.
ANS: B Toxoplasma gondii infection is an opportunistic infection that causes an encephalitis but poses only a rare threat to immunocompetent individuals The nurse would perform ongoing neurologic assessments. Contact and Protective Precautions are not needed. Good respiratory assessments are important to the client, but toxoplasmosis will demonstrate neurologic signs and symptoms.
A nurse is providing education about HIV risks at a health fair. What groups would the nurse include as needing to be tested for HIV on an annual basis? (Select all that apply.) a. Anyone who received a blood product in 1989 b. Couples planning on getting married c. Those who are sexually active with multiple partners d. Injection drugs users e. Sex workers and their customers f. Adults over the age of 65 years
ANS: B, C, D, E The CDC recommends that HIV testing would be performed on those who received a transfusion between 1978 and 1985 only. People planning on getting married should be tested and all sexually active people should know their HIV status. Those engaged in sex work and their customers should also be tested, as well as injection drug users. Those over the age of 65 years need a one-time screen.
A client with HIV-III has oral thrush and difficulty eating. What actions does the nurse delegate to the assistive personnel (AP)? (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. f. Offer the client soft foods like gelatin or pudding.
ANS: B, C, E, F The AP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Soft foods and liquids are tolerated better than harder foods. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and would not be used.
The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive
ANS: C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. "Inflammatory" is not a type of immunity.
A client with known HIV-II 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 would the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the primary health care provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.
ANS: C Since this client's CD4+ cell count is so low, he or she may have energy, or the inability to mount an immune response to the TB test. The client also appears to have progressed to HIV-III. The nurse would first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the primary health care 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.
The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T-cells c. Natural killer cells d. Regulator T-cells
ANS: D Regulator T-cells help prevent hypersensitivity to one's own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Regulator T-cells have an inhibitory action on the immune system. Cytotoxic T-cells are effective against self cells infected by parasites such as viruses or protozoa.
A client with HIV-III and 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 lb (1 kg)/1 mo.
ANS: 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. Choosing high-protein food is important, but only if the client eats and absorbs the nutrients.
The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane and he missed all of yesterday's dosages. What action does the nurse recommend? A. Take today's dosages as normally prescribed and continue to follow your therapy program. B. Don't worry. Unless you miss your drugs for 4 days consecutively, there is not a problem. C. Take double doses of the drugs for the next 2 days and do not have sex for at least 4 days. D. Go to the nearest emergency department and have an immediate blood test for assessment of viral load.
Answer: A Rationale: One day of missing the drugs is not good but is unlikely to cause drug resistance if 90% of the drugs within any 1 month are taken on time and at proper dosages. The client should not be taught that anything under 4 days of missing drugs is okay. Doubling the next day's doses does not make up for missing doses. The viral load will not change in this short of a time period.
Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? Activating the viral enzyme "integrase" within the infected host's cells Binding of the virus to the CD4+ receptor and either of the two co-receptors Clipping the newly generated viral proteins into smaller functional pieces Fusing of the newly created viral particle with the infected cell's membrane
Answer: B Rationale: Entry inhibitors work by binding to and blocking the CCR5 receptors on CD4+ T-cells, the main target of HIV. In order to successfully enter and infect a host cell, the virus must have its gp120 protein attach to the CD4 receptor and have its gp41 bind to the CD4+ T cell's CCR5 receptor. Viral binding to both receptors is required for infection. By blocking the HIV's attachment to the CCR5 receptor, infection is inhibited.
Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 X 109/L) to 400 cells/mm3 (0.2 X 109/L) indicates to the nurse that more teaching is needed? A. "Now my viral load is also probably lower." B. "I am so relieved that my drug therapy is working." C. "Although I am still HIV positive, at least I no longer have AIDS." D. "This change means I am less likely to develop an opportunistic infection."
Answer: C Rationale: A diagnosis of AIDS (HIV-III) requires that the adult be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 (0.2 X 109/L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3 [0.2 X 109/L]) or an opportunistic infection. Once HIV-III (AIDS) is diagnosed, even if the patient's T-cell count improves or if the percentage rises above 14%, or the infection is successfully treated, the AIDS diagnosis remains.
Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors? Activating the viral enzyme "integrase" within the infected host's cells Binding of the virus to the CD4+ receptor and either of the two co-receptors Clipping the newly generated viral proteins into smaller functional pieces Fusing of the newly created viral particle with the infected cell's membrane
Answer: C Rationale: HIV particles are made within the infected CD4+ T-cell, using the host cell's protein synthesis processes. The new virus particle is made as one long inactive protein strand. The strand is clipped by the enzyme HIV protease into smaller active pieces. Protease inhibitors block the enzyme from creating active viral pieces that can leave the cell and infect other cells.
Which type of immunity will the nurse initiate by administering an infusion of IV immunoglobulin to a client? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity
Artificial passive immunity The client will be receiving antibodies made in the body of another person and thus, is not actively involved in the production of these antibodies. That makes the immunity passive rather than active. Because the client is making the antibodies in response to an injection (vaccination) rather than in response to actually being sick with influenza, the immunity is artificial.
Which conditions or factors will the nurse teach at a community seminar as probable transmission routes for HIV? (Select all that apply.) Breast-feeding Having unprotected intercourse with multiple partners Being bitten by mosquitos Sitting on public toilets Using injection drugs Changing a diaper on an HIV positive child
Breast-feeding Having unprotected intercourse with multiple partners Using injection drugs
Which laboratory results does the nurse expect to decrease in a client who has untreated HIV-III (AIDS)? (Select all that apply.) CD4+ T-cell CD8+ T-cell Total white blood cell count Lymphocytes HIV antibodies Viral load
CD4+ T-cell Total white blood cell count Lymphocytes
Which statements about the transmission of HIV are true? (Select all that apply.) The most common transmission route is casual contact. Clients with HIV-III and no drug therapy are very infectious. HIV may be transmitted only during the end stages of the disease. Newly infected clients with a high viral load are very infectious. HIV-positive clients who have an undetectable viral load appear to not transmit the disease. Even with appropriate drug therapy, most clients infected with HIV live only about 5 years after diagnosis.
Clients with HIV-III and no drug therapy are very infectious. Newly infected clients with a high viral load are very infectious. HIV-positive clients who have an undetectable viral load appear to not transmit the disease.
Which concept is the highest priority for the nurse to consider in planning care for the client with HIV-III who has candidial stomatitis? Gas exchange Cellular regulation Comfort Nutrition
Comfort
A client diagnosed with acquired immunodeficiency syndrome (AIDS) shares with the nurse feelings of social isolation. Which strategy should the nurse suggest as the most useful way to decrease the client's stated loneliness? Reinstituting contact with the client's family, who live in a distant city Contacting a support group for clients with AIDS that is available in the local region Using the Internet or the computer to facilitate communication while maintaining isolation Using the television and newspapers to maintain a feeling of being "in touch" with the world
Contacting a support group for clients with AIDS that is available in the local region Rationale: The nurse encourages the client to maintain social contact and support and assists the client with reducing barriers to social contact. This can include educating the client's family about the disease and its transmission, as well as suggesting the use of community resources and support groups. Option 1, although feasible, is less likely to address the client's current feelings of loneliness. Options 3 and 4 will not decrease the client's loneliness.
Which signs and symptoms does the nurse expect to find in a client diagnosed with Pneumocystis jiroveci infection? Dyspnea, tachypnea, persistent dry cough, and fever Cough with copious thick sputum, fever, and dyspnea Substernal chest pain and difficulty swallowing Fever, persistent cough, and vomiting blood
Dyspnea, tachypnea, persistent dry cough, and fever
A client diagnosed with acquired immunodeficiency syndrome (AIDS) has a problem with nutrition resulting in a weight loss. The nurse has instructed the client regarding methods of increasing weight for health maintenance. The nurse determines that there is a need for further instruction if the client states the need to implement which measure? Eat low-calorie snacks between meals. Eat small, frequent meals throughout the day. Consume nutrient-dense foods and beverages. Keep easy-to-prepare foods available in the home.
Eat low-calorie snacks between meals. Rationale: The client who has a problem with nutrition and is losing weight should take in nutrient-dense and high-calorie meals and snacks. The client should also eat small, frequent meals throughout the day. The client is encouraged to eat favorite foods to keep intake up and plan meals that are easy to prepare. The client should also avoid taking fluids with meals in order to increase food intake before satiety occurs.
A client with AIDS is having difficulty maintaining body weight. Which intervention will the nurse provide? Select all that apply. Ensure regular mouth care. Provide three large meals daily. Encourage low fat food choices. Provide foods that are high in calories. Encourage drinking at least 1 L of fluid per day. Collaborate with the registered dietician nutritionist.
Ensure regular mouth care. Encourage low fat food choices. Provide foods that are high in calories. Collaborate with the registered dietician nutritionist. Clients should be drinking at least 2 to 3 L of fluids per day. Collaboration with the dietician is important to include high calorie, high protein foods. Avoid dietary fat, because fat intolerance often occurs as a result of the disease and as a side effect of some antiretroviral drugs. Provide small, frequent meals as they are often better tolerated than large meals. Mouth care can improve appetite.
The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection? Nausea and vomiting Fever and exertional dyspnea An arterial blood gas pH of 7.40 A respiratory rate of 20 breaths per minute
Fever and exertional dyspnea Rationale: Fever and exertional dyspnea are signs of Pneumocystis jiroveci pneumonia, which is a common, life-threatening opportunistic infection that afflicts those with AIDS. Option 1 is not associated with respiratory infection. Options 3 and 4 are normal findings.
A client reports having unprotected intercourse and is concerned about exposure to HIV. The nurse will assess whether the client has which initial symptom? Lymphocytopenia Flu-like symptoms Opportunistic infection Reduced numbers of CD4+ T-cells
Flu-like symptoms When a person is infected with HIV, the first manifestations are flu-like symptoms including fever, night sweats, chills, headache, and muscle aches. As time passes, CD4+ T-cells are infected and taken out of service. This cell count drops to below-normal levels, and those that remain may not function normally. Lymphocytopenia (decreased lymphocyte counts) occurs as a result. Also, as the CD4+ T-cell level drops, the client is at risk for bacterial, fungal, and viral infections, as well as some opportunistic cancers.
Which part of the HIV infection process is disrupted by the antiretroviral drug class of nucleoside reverse transcriptase inhibitors (NRTIs)? Activating the viral enzyme "integrase" within the infected host's cells Binding of the virus's gp120 protein to one of the CD4+ coreceptors Clipping the newly generated viral proteins into smaller functional pieces Forming counterfeit bases that prevent DNA synthesis and viral replication
Forming counterfeit bases that prevent DNA synthesis and viral replication
Which precautions are most important for the nurse to teach as part of health promotion for inflammation and immunity to an 88-year-old client? (Select all that apply.) Get an influenza vaccination every year. Wear gloves when working in your garden. Avoid performing any level of aerobic exercise. Consider moving into an assisted living facility. Be sure to have a tuberculosis skin test every year. Report any temperature elevation to your primary health care provider immediately.
Get an influenza vaccination every year. Wear gloves when working in your garden. Report any temperature elevation to your primary health care provider immediately. Older clients have overall reduced immunity and a higher risk for developing influenza and any other respiratory tract infection. They should receive annual influenza vaccinations. The skin of older adults is thinner, drier, and a greater risk for injury and infection. Wearing gloves when gardening can help prevent injury and reduce the risk for infection. Older clients often do not have greatly elevated temperatures during infection, which contributes to the infection being overlooked until it becomes serious. Thus, older clients should report any increase in temperature above their normal range to identify infections at earlier stages. TB skin tests may be falsely negative in older clients with reduced immunity and annual testing is of no real benefit. Healthy older clients who are cognitively intact and able to care for themselves have no need to change their living arrangements unless they so desire. Older clients can still engage in low-impact aerobic exercise under the supervision of their primary health care provider.
What type of health problem will the nurse expect to see in a client who has very few regulator T cells? Increased severity of allergic and other hypersensitivity reactions Decreased ability to recognize non-self cells Decreased immunoglobulin production Increased risk for cancer development
Increased severity of allergic and other hypersensitivity reactions Regulator T-cells (Tregs) function to limit the actions of general and specific responses. These cells prevent over-responses to the presence of "foreign proteins" within a person's environment. People who are deficient in these cells have more severe hypersensitivity reactions, allergies, and autoimmune responses.
With which antiretroviral drug class will the nurse teach clients to prevent harm by reporting any new onset muscle weakness and muscle pain to the immunity health care provider? Protease inhibitors Integrase inhibitors Fusion inhibitors Nucleoside reverse transcriptase inhibitors
Integrase inhibitors
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. Keep liquids at the bedside. Place a towel over the pillowcase. Make sure the pillow has a plastic cover. Keep a change of bed linens nearby in case they are needed. Administer an antipyretic after the client has a spike in temperature.
Keep liquids at the bedside. Place a towel over the pillowcase. Make sure the pillow has a plastic cover. Keep a change of bed linens nearby in case they are needed. Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at the bedside to drink.
Which practices are generally recommended to prevent sexual transmission of HIV? (Select all that apply.) Latex or polyurethane condoms for genital and anal intercourse Natural-membrane condoms for genital and anal intercourse Water-based lubricant with a latex condom Oral contraceptives taken consistently Latex dental dam genital and anal intercourse Latex gloves for finger or hand contact with the vagina or rectum
Latex or polyurethane condoms for genital and anal intercourse Water-based lubricant with a latex condom Latex dental dam genital and anal intercourse Latex gloves for finger or hand contact with the vagina or rectum
How do immune system cells differentiate between normal, healthy body cells and non-self cells within the body? All normal, healthy body cells are considered a part of the immune system. Immune system cells recognize normal healthy body cells by the presence of the nucleus, a structure that is lacking in non-self cells. Non-self cells are easily identified by the immune system cells because non-self cells are much larger than normal, healthy body cells. Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as "foreign" by immune system cells.
Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as "foreign" by immune system cells. Normal, healthy body cells all express surface proteins that are unique to the person, coded by the major histocompatibility genes. Non-self cells express different cell surface proteins. Immune system cells can distinguish between their own surface proteins and all others.
A client has been admitted to the medical-surgical floor with multiple problems. Which assessment finding does the nurse identify that is consistent with AIDS? Select all that apply. Persistent pain Persistent diarrhea Kaposi's sarcoma Wasting syndrome Esophageal candidiasis
Persistent pain Persistent diarrhea Kaposi's sarcoma Wasting syndrome Esophageal candidiasis All assessment findings are consistent with AIDS.
What is the first action a nurse should take after sustaining a needlestick injury after injecting a client who is known to be HIV positive? Send the syringe and needle to the laboratory for analysis of viral load. Go to the employee clinic for postexposure prophylaxis. Thoroughly scrub and flush the puncture site. Inform the charge nurse.
Thoroughly scrub and flush the puncture site.
A client who engages in sex with men and women asks the nurse about ways to prevent HIV transmission. Which method will the nurse teach? Select all that apply. Begin antiviral drug therapy Take an HIV home screening test Engage only in vaginal intercourse Use condoms during sexual activity Discuss PrEP with a health care provider
Use condoms during sexual activity Discuss PrEP with a health care provider Clients who wish to prevent HIV transmission should use condoms during sexual activity to reduce risk of exposure. Clients who are HIV-negative but at high risk for exposure to HIV should be taught to discuss PrEP with a health care provider. Beginning antiviral drug therapy is reserved for clients who have tested HIV positive. Taking an HIV home screening test may reveal the client's HIV status, but this does not prevent transmission. Engaging only in vaginal intercourse does not assure that HIV will not be transmitted.
Which laboratory test does the nurse analyze to determine the effectiveness of combination antiretroviral drug therapy in an HIV-positive client? Western blot analysis Viral load testing Enzyme-linked immunosorbent assay Fourth generation testing
Viral load testing
