Chapter 15 Infection and Human Immunodeficiency Virus Infection

The three antibiotic-resistant bacteria that are of most current concern in North America are ____________________, ____________________, and ____________________.

Methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant enterococci (VRE); penicillin- resistant Streptococcus pneumoniae (PRSP).

What are the recommended measures to prevent the transmission of health care-associated infections (HAIs) (select all that apply)? a. Empty bedpans as soon as possible b. Limit fresh flowers in patient rooms c. Remove urinals from bedside tables d. Use personal protective equipment e. Hand washing or alcohol-based sanitizing f. Have patients wear sandals in the shower

d, e. Hand washing and the use of alcohol-based sanitizers and personal protective equipment (e.g., gloves) will prevent health care-associated infections (HAIs). Although the other interventions will not hurt a patient and they are good practice, they will not prevent HAIs.

A patient identified as HIV antibody-positive 1 year ago manifests acute HIV infection but does not want to start antiretroviral therapy at this time. What is an appropriate nursing intervention for the patient at this stage of illness? a. Assist with end-of-life issues b. Provide care during acute exacerbations c. Provide physical care for chronic diseases d. Teach the patient about immune enhancement

d. After a patient has positive HIV antibody testing and is in acute disease, the overriding goal is to keep the viral load as low as possible and to maintain a functioning immune system. The nurse should provide teaching regarding ways to enhance immune function to prevent the onset of opportunistic diseases in addition to teaching about the spectrum of the infection, options for care, signs and symptoms to watch for, ways to prevent HIV spread, and ways to adhere to treatment regimens.

What finding supports the diagnosis of acquired immunodeficiency syndrome (AIDS) in the individual with HIV? a. Flu-like symptoms b. Oral hairy leukoplakia c. CD4+ T cells 200-500/μL d. Cytomegalovirus retinitis

d. Cytomegalovirus retinitis could be an opportunistic viral infection that occurs when AIDS is diagnosed. Flu-like symptoms occur in the acute HIV infection stage. CD4+ T cells drop to 200-500/μL and oral hairy leukoplakia are seen in the symptomatic infection stage of HIV.

The nurse realizes that the patient understands the teaching about decreasing the risk for antibiotic-resistant infection when the patient says which of the following? a. "I know I should take the antibiotic for one day after I feel better." b. "I want an antibiotic ordered for my cold so I can feel better sooner." c. "I always save some pills because I get the illness again after I first feel better." d. "I will follow the directions for taking the antibiotic so I will get over this infection."

d. One of the most important factors in the development of antibiotic-resistant strains of organisms has been inappropriate use of antibiotics. Following directions regarding timing and completion of antibiotics will not allow antibiotic-resistant bacteria to develop. Antibiotics are not effective against viruses, which cause colds and flu. Not completing the antibiotic may allow the hardiest bacteria to survive and multiply and the potential development of an antibiotic-resistant infection.

Why do opportunistic diseases develop in an individual with AIDS? a. They are side effects of drug treatment of AIDS. b. They are sexually transmitted to individuals during exposure to HIV. c. They are characteristic in individuals with stimulated B and T lymphocytes. d. These infections or tumors occur in a person with an incompetent immune system.

d. Organisms that are nonvirulent or that cause limited or localized diseases in an immunocompetent person can cause severe, debilitating, and life-threatening infections in persons with impaired immune function.

Indicate below which event (from Question 9) of HIV infection of a cell is controlled by each drug. This would also be the mechanism of action of the drug. DRUG-----------------MOA? Entry inhibitors Reverse transcriptase inhibitors Integrase inhibitors Protease inhibitors

Entry inhibitors(MOA) Inhibit entry into cell (step 2 from Question 9) Reverse transcriptase inhibitors(MOA) Inhibit conversion of viral RNA to single-stranded viral DNA with the assistance of the enzyme reverse transcriptase (step 3 from Question 9) Integrase inhibitors(MOA) Viral DNA is spliced into cell genome using the enzyme integrase (step 5 from Question 9) Protease inhibitors(MOA) Inhibit cutting of the long strands of viral RNA in the presence of the enzyme protease (step 7 from Question 9)

Identify three methods to eliminate or reduce the risk for HIV transmission related to sexual intercourse and drug use and two methods to reduce the risk for perinatal transmission. Sexual Intercourse a.___b.___c.____ Drug Use a.___b.____c.____ Perinatal Transmission a.___b.____

Sexual Intercourse • Abstain from sexual activity • Noncontact sexual activities (outercourse) • Use of male or female condoms during sexual activity Drug Use • Abstain from drug use • Do not share equipment • Use alternative routes to injecting • Do not have sexual intercourse while under the influence of drugs Perinatal Transmission • Use family planning to avoid pregnancy • Use antiretroviral therapy to reduce the risk of transmission

To what is the increase in emerging and untreatable infections attributed (select all that apply)? a. The evolution of new infectious agents b. Use of antibiotics to treat viral infections c. Human population encroachment into wilderness areas d. Transmission of infectious agents from humans to animals e. An increased number of immunosuppressed and chronically ill people

a, b, c, e. Infectious agents, such as the human immunodeficiency virus (HIV) and hantavirus, have evolved to affect humans through closer association with animals as human populations push into wild animal habitats. The transfer of infectious agents from animals to humans has also resulted in West Nile virus and avian flu. Bacterial infections have also become untreatable as the result of genetic and biochemical changes stimulated by unnecessary or inadequate exposure to antibiotics. The increased number of immunosuppressed and chronically ill people also increase the emergence of untreatable infections.

Place the following events of HIV infection of a cell in sequence from 1 (first) to 7 (last). ___a.Viral RNA is converted to single-stranded viral DNA with assistance of reverse transcriptase ___b. Viral DNA is spliced into cell genome using the enzyme integrate ___c. gp 120 proteins on viral envelope combine with CD4 receptors of body cells ___d. Cell replicates infected daughter cells and makes more HIV e.___Viral RNA and reverse transcriptase enzyme enter host CD4+ T cell __f.Long strands of viral RNA are cut in the presence of protease __g.Single-stranded viral DNA replicates into double-stranded DNA

a. 3; b. 5; c. 1; d. 6; e. 2; f. 7; g. 4

A 78-year-old patient has developed Haemophilus influenzae. In addition to standard precautions, what should the nurse use to protect herself and other patients when working within 3 feet of the patient? a. Mask b. Gown c. Gloves d. Shoe covers

a. A mask will be worn even 3 feet from the patient to avoid droplet transmission. The gown and gloves will be used as with standard precautions, when working closely with the patient and there is a risk of contamination.

What is a primary reason that the normal immune response fails to contain the HIV infection? a. CD4+ T cells become infected with HIV and are destroyed. b. The virus inactivates B cells, preventing the production of HIV antibodies. c. Natural killer cells are destroyed by the virus before the immune system can be activated. d. Monocytes ingest infected cells, differentiate into macrophages, and shed viruses in body tissues.

a. Activated CD4+ T cells are an ideal target for HIV because these cells are attracted to the site of concentrated HIV in the lymph nodes, where they become infected through viral contact with CD4 receptors. CD4+ T cells normally are a major component of the immune system and their infection renders the immune system ineffective against HIV and other agents. The virus does not affect natural killer cells and B lymphocytes are functional early in the disease, as evidenced by positive antibody titers against HIV. Monocytes do ingest infected cells and may become sites of HIV replication and spread the virus to other tissue but this does not make the immune response ineffective.

A patient with advanced AIDS has a nursing diagnosis of impaired memory related to neurologic changes. In planning care for the patient, what should the nurse set as the highest priority? a. Maintain a safe patient environment b. Provide a quiet, nonstressful environment to avoid overstimulation c. Use memory cues such as calendars and clocks to promote orientation d. Provide written instructions of directions to promote understanding and orientation

a. All of the nursing interventions are appropriate for a patient with impaired memory but the priority is the safety of the patient when cognitive and behavioral problems impair the ability to maintain a safe environment.

Which opportunistic disease associated with AIDS is characterized by hyperpigmented lesions of skin, lungs, and gastrointestinal (GI) tract? a. Kaposi sarcoma b. Candida albicans c. Herpes simplex type 1 infection d. Varicella-zoster virus infection

a. Hyperpigmented lesions of skin, lungs, and GI tract are seen in Kaposi sarcoma. Candida albicans is a common yeast infection of the mouth, esophagus, GI tract, or vagina. Herpes simplex type 1 infection has oral and mucocutaneous vesicular and ulcerative lesions. Varicella- zoster virus infection or shingles is a maculopapular, pruritic rash and is treated with acyclovir.

In each of the following situations identify which option has the highest risk for human immunodeficiency virus (HIV) transmission? a. Transmission to women OR to men during sexual intercourse b. Hollow-bore needle used for vascular access OR used for IM injection c. First 2 to 6 months of infection OR 1 year after infection d. Perinatal transmission from HIV-infected mothers taking antiretroviral therapy OR HIV-infected mothers using no therapy e. A splash exposure of HIV-infected blood on skin with an open lesion OR a needle-stick exposure to HIV-infected blood

a. women; b. vascular access; c. first 2 to 6 months of infection; d. HIV-infected mothers using no therapy; e. needle-stick exposure to HIV-infected blood

After teaching a patient with HIV infection about using antiretroviral drugs, the nurse recognizes that further teaching is needed when the patient says a. "I should never skip doses of my medication, even if I develop side effects." b. "If my viral load becomes undetectable, I will no longer be able to transmit HIV to others." c. "I should not use any over-the-counter drugs without checking with my health care provider." d. "If I develop a constant headache that is not relieved with aspirin or acetaminophen, I should report it within 24 hours."

b. An undetectable viral load in the blood does not mean that the virus is gone; it is still present in lymph nodes and other organs. Transmission is still possible and use of protective measures must be continued.

A patient comes to the clinic and requests testing for HIV infection. Before administering testing, what is most important for the nurse to do? a. Ask the patient to identify all sexual partners b. Determine when the patient thinks exposure to HIV occurred c. Explain that all test results must be repeated at least twice to be valid d. Discuss prevention practices to prevent transmission of the HIV to others

b. Because there is a median delay of several weeks after infection before antibodies can be detected, testing during this "window" may result in false-negative results. Risky behaviors that may expose a person to HIV should be discussed and possible scheduling for repeated testing done. Positive results on initial testing will be verified by additional testing. Identification of sexual partners and prevention practices are important but do not relate immediately to the testing situation.

A patient with diarrhea has been diagnosed with Clostridium difficile. Along with standard precautions, which kind of transmission-based precautions will be used when the nurse is caring for this patient? a. Droplet precautions b. Contact precautions c. Isolation precautions d. Airborne precautions

b. Contact precautions are used with standard precautions when microorganisms can be transmitted by direct patient contact.

An 82-year-old male patient with pneumonia who is in the intensive care unit (ICU) is beginning to have decreased cognitive function. What should the nurse first suspect as a potential cause of this change? a. Fatigue c. ICU psychosis b. Infection d. Medication allergy

b. Infection in older adults often has atypical presentations, cognitive and behavioral changes occurring before fever, pain, or altered laboratory values. Fatigue and ICU psychosis (if the patient is in the ICU) could be occurring but these are not as dangerous for the patient as infection can be. Cognitive and behavioral changes are not typical manifestations of medication allergy.

Which characteristic corresponds with the acute stage of HIV infection? a. Burkitt's lymphoma b. Temporary fall of CD4+ T cells c. Persistent fevers and night sweats d. Pneumocystis jiroveci pneumonia

b. The symptoms of acute HIV infection occur 2 to 4 weeks after initial infection and last for 1 to 2 weeks. The CD4+ T-cell counts fall temporarily but quickly return to baseline levels. Burkitt's lymphoma and Pneumocystis jiroveci pneumonia are two of the opportunistic diseases that can occur in acquired immunodeficiency syndrome (AIDS). Persistent fevers and drenching night sweats occur in the symptomatic infection stage.

Treatment with two nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor (PI) is prescribed for a patient with HIV infection who has a CD4+ T-cell count of <400/μL. The patient asks why so many drugs are necessary for treatment. What should the nurse explain as the primary rationale for combination therapy? a. Cross-resistance between specific antiretroviral drugs is reduced when drugs are given in combination. b. Combinations of antiretroviral drugs decrease the potential for development of antiretroviral-resistant HIV variants. c. Side effects of the drugs are reduced when smaller doses of three different drugs are used rather than large doses of one drug. d. When CD4+ T-cell counts are <500/μL, a combination of drugs that have different actions is more effective in slowing HIV growth.

b. The use of potent combination antiretroviral therapy limits the potential for development of resistance to antiretroviral medications, the major factor that limits the ability of antiretroviral drugs to inhibit virus replication and delay disease progression. The drugs selected should be ones with which the patient has not been previously treated and that are not cross-resistant with antiretroviral agents previously used by the patient.

The "rapid" HIV antibody testing is performed on a patient at high risk for HIV infection. What should the nurse explain about this test? a. The test measures the activity of the HIV and reports viral loads as real numbers. b. This test is highly reliable, and in 5 minutes the patient will know if HIV infection is present. c. If the results are positive, another blood test and a return appointment for results will be necessary. d. This test detects drug-resistant viral mutations that are present in viral genes to evaluate resistance to antiretroviral drugs.

c. Although the "rapid" test is highly reliable and results are available in about 20 minutes, if results are positive from any testing, blood will be drawn for more specific enzyme immunosorbent assay (EIA) or Western blot testing and another visit will be necessary to obtain the results of the additional testing. CD4+ T-cell counts are not used for screening but rather are used to monitor the progression of HIV infection and new assay tests measure resistance of the virus to antiviral drugs.

What is one of the most significant factors in determining when to start antiretroviral therapy in a patient with HIV infection? a. Whether the patient has high levels of HIV antibodies b. Confirmation that the patient has contracted HIV infection c. The patient's readiness to commit to a complex, lifelong, uncomfortable drug regimen d. Whether the patient has a support system to help manage the costs and side effects of the drugs

c. Guidelines for initiating antiretroviral therapy (ART) are being updated continuously because of the development of alternative drugs and problems with long-term side effects and compliance with regimens. In the past, ART was always recommended at the time of HIV infection diagnosis but today new guidelines suggest that treatment can be delayed until higher levels of immunosuppression are observed. Whenever treatment is started, an important consideration is the patient's readiness to initiate ART because adherence to drug regimens is a critical component of the therapy.

Prophylactic measures that are routinely used as early as possible in HIV infection to prevent opportunistic and debilitating secondary problems include administration of a. isoniazid (INH) to prevent tuberculosis b. trimethoprim/sulfamethoxazole (TMP/SMX) for toxoplasmosis c. vaccines for pneumococcal pneumonia, influenza, and hepatitis A and B d. varicella-zoster immune globulin (VZIG) to prevent chickenpox or shingles

c. Pneumococcal pneumonia, influenza, and hepatitis A and B vaccines should be given as early as possible in HIV infection while there is still immunologic function. Isoniazid (INH) is used for 9 to 12 months only if a patient has reactive purified protein derivative (PPD) >5 mm, has had high-risk exposure, or has prior untreated positive PPD. Trimethoprim/sulfamethoxazole (TMP/ SMX) is initiated when CD4+ T-cell count is <200/μL or when there is a history of Pneumocystis jiroveci pneumonia (PCP) and varicella-zoster immune globulin (VZIG) is indicated only after significant exposure to chickenpox or shingles in patients with no history of disease or a negative varicella-zoster virus (VZV) antibody test. Prophylaxis for other opportunistic diseases is noted in eTable 15-2.

Which characteristics describe Pneumocystis jiroveci infection, an opportunistic disease that can be associated with HIV? a. May cause fungal meningitis b. Diagnosed by lymph node biopsy c. Pneumonia with dry, nonproductive cough d. Viral retinitis, stomatitis, esophagitis, gastritis, or colitis

c. Pneumocystis jiroveci infection is characterized by pneumonia with a dry, nonproductive cough. Cryptococcus infection may cause fungal meningitis. Non-Hodgkin's lymphoma is diagnosed by lymph node biopsy. Cytomegalovirus infection is characterized by viral retinitis, stomatitis, esophagitis, gastritis, or colitis.