Patho PrepU Ch.12 (Disorders of the Immunity)

A client describes himself as being "devastated" after hearing that his HIV test has come back positive. Which response by the nurse is most appropriate?

"It's entirely normal to feel that way. We are going to try our best to help you get all the support you need." Explanation: The nurse's best response is to validate the client's statement and to affirm a commitment to support him. It is presumptuous to conclude that by saying he is "devastated" he means that he is ashamed or afraid. Similarly, it is presumptuous for the nurse to claim that he or she knows how the client is feeling.

What is a characteristic indicator that an individual is in the latent phase of HIV?

Lack of symptoms Explanation: The three phases experienced are primary infection phase, chronic asymptomatic or latency phase, and overt AIDS phase. Mononucleosis-like symptoms and high viral loads are seen in the primary infection phase, whereas the AIDS phase is characterized with opportunistic infections.

What is the priority intervention for a nurse caring for a client with wasting syndrome from HIV?

Promote nutritional intake Explanation: Wasting syndrome is defined as an AIDS-related illness with the manifestations of involuntary weight loss of at least 10% of baseline, diarrhea or chronic weakness and fever, but no other infections or neoplasms. It is treated with nutritional interventions such as oral supplements or enteral or parenteral nutrition.

The nurse is reviewing the client's medical record for the results of a Western blot test with the understanding that:

the Western blot is used to confirm a diagnosis of HIV infection. Explanation: The Western blot test is more specific than the ELISA, and in the case of false-positive ELISA, the Western blot test can identify the person as uninfected. ELISA tests have high false-positive rates.

The nurse is preparing to administer a unit of blood to a client. The client says that he is not sure he wants to give consent to receive the blood transfusion because he does not want to get AIDS from the blood. Select the best response from the nurse.

"All blood is now tested for the AIDS virus, so the risk of getting AIDS from a blood transfusion is extremely low." Explanation: Some transfusions of whole blood, plasma, platelets, or blood cells before 1985 resulted in the transmission of HIV. Since 1985, all blood donations in the United States have been screened for HIV, so this is no longer a transmission risk; however, infection can occur from transfused blood that was screened for HIV antibody and found negative because the donor was recently infected and still in the window period.

When a client who has been newly diagnosed with HIV asks, "What are the chances that I can be cured?," what is the nurse's most therapeutic response?

"Although there is no current treatment that provides a possible cure, there are ones that have successfully managed the infection." Explanation: There is no cure for HIV infection. The medications that are currently available to treat HIV infection decrease the amount of virus in the body, but they do not eradicate HIV. After HIV infection is confirmed, a baseline evaluation should be done. This evaluation should include a complete history and physical examination and baseline laboratory tests including a complete blood count with differential. Routine follow-up care of a stable, asymptomatic person infected with HIV should include a history and physical examination along with CD4+ cell count and viral load testing every 3 to 4 months. People who are symptomatic may need to be seen more frequently. Therapeutic interventions are determined by the level of disease activity based on the viral load, the degree of immunodeficiency based on the CD4+ cell count, and the appearance of specific opportunistic infections.

The nurse working at a community clinic is caring for a young male client. The client asks the nurse if he could get AIDS from being sprayed in the face with breast milk. Select the best response by the nurse.

"Breast milk can contain the virus that causes AIDS, but to be infected, the milk needs to be in contact with your mucous membranes or an open sore." Explanation: HIV can be transmitted through breast-feeding; however, transmission requires contact with mucous membranes or an open sore.

Which statement from a group of young adults demonstrates the need for further teaching related to HIV and prevention of the spread of HIV?

"Having oral sex is one way I can prevent passing on HIV to my partner." Explanation: Sexual contact is the most frequent mode of HIV transmission. There is a risk of transmitting HIV when semen or vaginal fluids come in contact with a part of the body that lets them enter the bloodstream. This can include the vaginal mucosa, anal mucosa, and wounds or sores on the skin. Condoms are highly effective in preventing the transmission of HIV. Unprotected sex between men is still the main mode of transmission. During the window period, a person's HIV antibody test result will be negative, but he or she can still transmit the virus.

The nurse is teaching a group of college students about reducing the risk of HIV transmission during sexual relations. The nurse makes which appropriate teaching point?

"If a person has a sexually transmitted disease (STD), there is an increased risk for HIV infection." Explanation: Sexual contact is the most frequent mode of HIV transmission. This includes vaginal, oral, and anal sex. The HIV-infected person is infectious even when no symptoms are present and before seroconversion. People with other sexually transmitted diseases (STDs) are at increased risk for HIV. Natural or lambskin condoms do not provide the same protection from HIV as latex because of the larger pores in the material.

A college student has been called into the student health office because she tested positive for HIV on the enzyme-linked immunosorbent assay (ELISA). The student asks, "What is this Western blot assay going to tell you?" The best response by the health care provider is:

"The Western blot is a more sensitive assay that looks for the presence of antibodies to specific viral antigens." Explanation: The Western blot is a more sensitive assay than the EIA that looks for the presence of antibodies to specific viral antigens. In the case of a false-positive EIA result, the Western blot test can identify the person as uninfected. Technologic advances have led to new forms of testing, such as the oral test, home testing kits, and the new rapid blood test. Oral fluids contain antibodies to HIV. In the late 1990s, the FDA approved the OraSure test. The OraSure uses a cotton swab, which is inserted into the mouth for 2 minutes, placed in a transport container with preservative, and then sent to a laboratory for EIA and Western blot testing.

A client develops an immunodeficiency disorder after receiving chemotherapy for the treatment of lung cancer. The client asks the nurse if he was born with this deficiency. What is the nurse's best response?

"You have developed a secondary immunodeficiency disorder as a result of your chemotherapy." Explanation: Secondary immunodeficiency disorders develop later in life as a result of other pathophysiologic states such as malnutrition, disseminated cancers; infection of the cells of the immune system, most notably with human immunodeficiency virus, and treatment with immunosuppressant drugs, such as chemotherapeutic agents, corticosteroids, or transplant rejection medications.

Shortly after being diagnosed with HIV, a client has begun highly active antiretroviral therapy (HAART). The client asks, "My doctor tells me that my viral load is going down. What does that mean?" The nurse's best response is:

"Your HAART medications are working to slow the progression of the disease." Explanation: Antiviral therapies such as HAART are prescribed to slow the progression of AIDS and improve the overall quality of life and survival time of persons with HIV infection. Extension, not limitation, of the latent period is a goal. Minimizing transmission and preventing seroconversion are not normally achievable goals through drug therapy alone. The final 5% to 15% are long-term nonprogressors, who remain asymptomatic for 10 years or more after seroconversion, with stable CD4+ T-cell counts and low plasma HIV RNA levels.

Place the following in the sequence of the progression of HIV/AIDS on a cellular level.1)The HIV virus is uncoded.2)HIV attaches to the receptors on the CD4+ cell.3)DNA synthesis occurs by reverse transcription.4)Transcription of the DNA to form a single-strand messenger RNA.

2,1,3,4 Explanation: The first step involves the binding of the virus to the CD4+ T cell. The second step allows for the internalization of the virus. After attachment, the virus envelope peptides fuse to the CD4+ t-cell membrane. Fusion results in uncoding of the virus. The third step consists of DNA synthesis by reverse transcription. The fourth step is integration. The fifth step involves transcription of the double-stranded viral DNA to form a single-stranded messenger RNA.

Which client has the highest risk of contracting an opportunistic infection?

A client who has had HIV for 3 years and has a CD4+ count of 50 cells/μL Explanation: The lower the CD4+ T-cell count is, the higher the likelihood of contracting an opportunistic infection. In a client who is newly infected with HIV, the CD4+ T-cell count would he high, even though the viral load is high. Platelets are not an important factor when considering the opportunity for an infection.

The nurse is caring for several clients on the acute care floor. Which clients are at risk for the development of allergic responses to latex? Select all that apply.

A client with a history of atopic reactions A client with a history of food allergies A client with a history of delayed hypersensitivity reactions Explanation: While exposure to natural rubber latex is necessary for sensitization, other factors play a key role in the development of latex allergy. People with a history of atopic reactions, food allergies, and delayed hypersensitivity reactions are more likely to develop an allergic response to latex. A client with a history of otitis media or respiratory infections is no more likely to develop an allergy to latex than the general population.

The school nurse is preparing a lecture on HIV/AIDS for a health class of high school students. The nurse would know to include what information about the transmission of AIDS in her lecture? Select all that apply.

AIDS is transmitted through sexual contact. AIDS is transmitted through blood-to-blood contact. AIDS is transmitted from the mother to her unborn baby. Explanation: HIV is transmitted from one person to another through sexual contact, blood-to-blood contact, or perinatally. It is not transmitted through casual contact. Several studies involving more than 1000 uninfected, nonsexual household contacts with persons with HIV infection (including siblings, parents, and children) have shown no evidence of casual transmission. HIV is not spread by mosquitoes or other insect vectors.

A dental assistant comes to the clinic with reports of a rash on her hands that feel like they are coming from the gloves being worn. The nurse observes both hands with crusted and thickened areas. What type of education does the nurse anticipate providing to the client?

Apply a topical corticosteroid and avoid further contact with latex-containing products. Explanation: Type IV hypersensitivity reactions to latex gloves are the most common form of latex allergy seen. In this form of allergy, people usually develop a contact dermatitis to one of the chemical additives rather than the latex proteins within 48 to 96 hours of exposure. The contact dermatitis often affects the dorsum of the hands and is characterized by a vesicular, pruritic rash. When glove contact is continued, the area becomes crusted and thickened. Treatment is with topical corticosteroids during the acute phase and avoidance of all latex-containing products.

A client has been admitted to the hospital for the treatment of HIV infection, which has recently progressed to overt AIDS. Which nursing action should the nurse prioritize when providing care for this client?

Astute infection control and respiratory assessments Explanation: Although all of the cited assessments and interventions may be of some value, infection control and the early identification of potential respiratory infections are paramount in the care of clients with AIDS.

Which type of a hypersensitivity reaction involves failure of the development of self-tolerance?

Autoimmune reaction Explanation: A key feature of the immune system is its ability to differentiate between foreign antigens and self-antigens. The capacity of the immune system to differentiate self from non-self is called self-tolerance. The development of self-tolerance relies on two coordinated processes: central and peripheral.

Which statement about opportunistic pathogen infection in AIDS is true?

Becoming infected with an opportunistic pathogen is one requirement for the diagnosis of AIDS. Explanation: The diagnosis of AIDS is confirmed when a client's CD4+ count falls below 200 cells/μL or acquires an AIDS-defining illness (opportunistic disease). Opportunistic infections can infect healthy people, but they usually infect the immunocompromised, and they are serious. HIV attacks T cells.

Which client would be diagnosed with wasting syndrome?

Client with HIV, fever, diarrhea, and significant involuntary weight loss Explanation: A client diagnosed with wasting syndrome (an AIDS-defining illness) would have chronic fever, diarrhea, and a significant involuntary weight loss (usually more than 10%) without an opportunistic infection. Pneumonia, Kaposi sarcoma, and herpes simplex and candidiasis are all opportunistic infection.

Which regimen serves as the rationale for AIDS treatment with antiretroviral therapy?

Combination therapy incorporating the five classes of antiretroviral drugs Explanation: Because different drugs act on various stages of the replication cycle, optimal treatment includes a combination of drugs, including reverse transcriptase inhibitors, protease inhibitors, fusion/entry inhibitors, and integrase inhibitors, and multidrug combination products. Each type of agent attempts to interrupt viral replication at a different point. Reference:

A client is diagnosed with a mild case of an autoimmune disorder and is beginning a treatment regimen. What is the mainstay of treatment with an autoimmune disorder?

Corticosteroids and immunosuppressants Explanation: Treatment of autoimmune disorders is dependent on the magnitude of the presenting manifestations and underlying mechanisms of the disease process. Because in many cases the pathophysiologic mechanisms are not always known, treatment may be purely symptomatic. Corticosteroids and immunosuppressive drugs are the mainstay of therapy directed at arresting or reversing the cellular damage caused by the autoimmune response. Plasmapheresis has been used in severe cases to remove autoreactive cells from circulation.

A client is suffering from the effects of the opportunistic infection, Cryptosporidium parvum. An important nursing intervention would be to encourage which action?

Hydration Explanation: Crytosporidium parvum has clinical features ranging from mild diarrhea to severe, watery diarrhea with a loss of up to several liters per day. Hydration is an important consideration.

A client with common variable immunodeficiency (CVID) is admitted to the hospital for treatment. Which type of treatment will the nurse be administering to the client?

IV immunoglobulin Explanation: Treatment methods for CVID are similar to those used for other primary humoral immunodeficiencies, with IVIg being the mainstay of therapy.

In an allograft collection of stem cells, which match has the lowest risk of rejection?

Identical HLA types matching 3 of 6 HLA loci Explanation: Donors with identical HLA types, matched for at least 3 of 6 HLA loci, are associated with the least risk of graft-versus-host disease or graft rejection. While loci match is important, 6 of 6 loci are not required. A distant relative is not a guarantee of the required match.

A client with hereditary angioneurotic edema (HAE) is experiencing an attack. Which priority intervention should the nurse be prepared to administer?

Maintaining a patent airway Explanation: Laryngeal edema is a life-threatening manifestation that can lead to complete airway obstruction and death without intervention. Although vomiting may occur due to the swelling of the structures of the gastrointestinal mucosa, the priority intervention would be maintaining a patent airway.

Systemic lupus erythematosus is best characterized by which principle?

Most clients have antinuclear antibodies present in their blood. Explanation: Clients diagnosed with systemic lupus erythematosus will most commonly have antinuclear antibodies in their blood. Lupus is primarily a disease of women and it is an autoimmune reaction.

Which disorder does the nurse know is considered to be an autoimmune disease?

Myasthenia gravis Explanation: Autoimmune disorders are those in which the immune system attacks body tissues. Some autoimmune disorders attack specific body systems while others are systemic. Systemic autoimmune disorders include rheumatoid arthritis, scleroderma, and systemic lupus erythematosus. Other autoimmune diseases include idiopathic thrombocytic purpura, Hashimoto thyroiditis, Type 1 diabetes mellitus, myasthenia gravis, primary biliary cirrhosis, temporal arteritis, Crohn's disease, and ulcerative colitis. Rhabdomyolysis is a disorder of muscle breakdown that typically follows injury or medications such as statins. Diverticulitis is inflammation of outpouchings of the colon. Osteoarthritis is joint destruction from wear and tear.

The nurse is caring for a client who has AIDS and suffers from wasting syndrome. What is the priority nursing consideration for this client?

Nutrition Explanation: The wasting syndrome is an AIDS-defining illness and is common in people with HIV infection or AIDS. Wasting syndrome is characterized by involuntary weight loss of at least 10% of baseline. Treatment for wasting includes nutritional interventions.

What is a common opportunistic infection in AIDS clients?

Pneumocystis jiroveci pneumonia (PCP) Explanation: PCP is a very common opportunistic infection in individuals with AIDS. It is a common bacteria found in households and does not routinely effect someone with a healthy immune system. Chancroid and syphilis are infections that do not occur commonly in the population in general, including those with AIDS. Myalgia is not an infection, but it is muscle pain, a common symptom of an infection.

What is the main effect of HIV infection?

Poor helper T-cell function Explanation: Helper T cells are also known as CD4+ T cells. These CD4+ T cells are necessary for normal immune function and are the main target of HIV.

What instruction will the nurse provide to a client with a new diagnosis of anaphylactic reaction to peanuts?

Routinely wear medical alert identification. Explanation: Clients with anaphylaxis have type I hypersensitivity reactions that can be triggered by the presence of minute amounts of the antigen. They should always wear or carry medical alert identification. With history of anaphylaxis, they should also carry epinephrine syringes for emergency administration. Waiting until the client stops breathing would put the person at risk of sudden death. Hypersensitivity reactions do not decrease over time, but may become more severe.

A client with cirrhosis has just received a liver transplant. Tissue rejection can be best prevented by what means?

Suppression of CD8+ cytotoxic T cells Explanation: T-cell-mediated graft rejection is called cellular rejection and is induced by two mechanisms: destruction of graft cells by CD8+ cytotoxic T cells and delayed hypersensitivity reactions triggered by CD4+ helper T cells. Neutrophil, complement, and macrophages are nonspecific inflammatory cells.

A nurse has just learned that her child has a life-threatening complement disorder known as hereditary angioneurotic edema (HAE). Due to deficiency in C1-INH, the nurse needs to be prepared for which possible life-threatening clinical manifestation?

Swelling of the airway Explanation: HAE is a rare, life-threatening complement disorder that results from deficiency of C1-inhibitor (HAE-C1-INH). It is an inherited autosomal dominant trait that causes mutation in the 11th chromosome. Deficiencies in C1-INH result in uncontrolled release of vasoactive substances that promote vascular permeability. The net result is development of tissue swelling in the subcutaneous tissues of the extremities, face/torso, or upper airway and GI tract. Laryngeal edema is a life-threatening manifestation that can lead to complete airway obstruction and death without interventions.

Antinuclear antibodies are characteristic of:

Systemic lupus erythematosus Explanation: The presence of antinuclear antibodies is most commonly assoicated with systemic lupus erythematosus.

The nurse understands that a positive ELISA test reported in a baby born to a woman who is HIV positive indicates:

The baby has antibodies from the mother and it is uncertain whether the baby is infected with HIV. Explanation: The diagnosis of HIV infection in children born to HIV-infected mothers is complicated by the fact that infants have the maternal anti-HIV IgG antibody for approximately 6 months. Consequently, infants born to HIV-infected women can be HIV-antibody-positive by ELISA for up to 18 months of age even though they are not infected with HIV.

An infant has a rare autosomal recessive disorder, ataxia-telangiectasia, that has recently been diagnosed. Which developmental milestone assists in diagnosing this disorder?

The child is beginning to walk. Explanation: Ataxia is the predominant neurodegenerative feature, which usually goes undiagnosed until the child beings to walk. Talking, dietary intake, and tooth development do not correlate with this diagnosis.

The treatment prescribed for an autoimmune disorder is primarily dependent upon what?

The current manifestations of the disease and the mechanisms that cause the disease process Explanation: Treatment of autoimmune disorders is dependent upon the magnitude of the presenting manifestations and underlying mechanisms of the disease process. Since in many cases the pathophysiologic mechanisms are not always known, treatment may be purely symptomatic. While corticosteroids are often use, they are not always the first line of treatment. The client's age and medical history can be factors in treatment choices but are not the primary consideration.

The type of hypersensitivity reaction that is mediated by IgG or IgM antibodies directed against target antigens on specific host cell surfaces or tissues is also known as which type of hypersensitivity reaction?

Type II Explanation: A type I hypersensitivity reaction is dependent on IgE-mediated activation of mast cells and basophils and the subsequent release of chemical mediators of the inflammatory response. Type II hypersensitivity reactions are mediated by IgG or IgM antibodies directed against target antigens on specific host cell surfaces or tissues and result in complement mediated phagocytosis and cellular injury. Type III hypersensitivity is caused by the formation of antigen-antibody immune complexes in the bloodstream, which are subsequently deposited in vascular epithelium or extravascular tissues and which activate the complement system and induce a massive inflammatory response. Type IV hypersensitivity involves tissue damage in which cell-mediated immune responses with sensitized T lymphocytes cause cell and tissue injury.

What is the most common mode of transmission of HIV?

Vaginal and anal intercourse Explanation: The most common method of transmission of HIV is from vaginal and anal sexual intercourse. Only 25% of newly diagnosed HIV infections are in those individuals who share needles. Transmission from mother to infant is the most common way children are affected but not the most common overall. Occupation exposure and blood transfusion are the least common of the choices provided.

The nurse is caring for a client with common variable immunodeficiency (CVID) disorder. Which clinical manifestation of the disorder is common with this client?

Viral pneumonia Explanation: Clinical manifestations of CVID can begin at any time of life and most commonly include recurrent bacterial and viral infections of the respiratory tract.

A 20-year-old male presents at the clinic complaining of severe fatigue, night sweats, and fever. While taking the client's history, he reports having multiple sexual partners and unprotected sex. HIV/AIDS is suspected. What diagnostic test would be ordered to confirm the diagnosis?

Western blot assay Explanation: The HIV antibody test procedure consists of screening with an enzyme immunoassay (EIA), also known as enzyme-linked immunosorbent assay (ELISA), followed by a confirmatory test, the Western blot assay, which is performed if the EIA is positive. The complete metabolic panel cannot diagnose HIV/AIDS. The diagnostic test for HIV/AIDS is the ELISA, not the ALEA. The confirmatory test for HIV/AIDS is not the Eastern blot test.

A client recently diagnosed with leukocyte adhesion deficiency (LAD) asks, "Why am I always sick with an infection?" Which response by the nurse explains this rare autosomal recessive disorder?

Your white blood cells are not able to leave the blood vessels and move into the area of infection." Explanation: Leukocyte adhesion deficiency (LAD) is a rare autosomal recessive disorder characterized by immunodeficiency, resulting in recurrent infections. A WBC differential will reveal extremely elevated levels of neutrophils (on the order of 6-10 times normal) because they are unable to leave the blood vessels. Certain integrins play an important role in allowing white blood cells to pass through the vessel wall, a process called transmigration.