ADN220 Test 3 HIV/AIDS NCLEX questions
A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4° F (39.1° C) b. Client with Bruton's agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
ANS: A A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.
The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands "HIV+" d. Wearing a mask within 3 feet of the client
ANS: A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.
The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse
ANS: A Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. 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 36 months. 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.
A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. 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 should 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; as more states recognize gay marriage, this issue will continue to evolve.
A client with human immune deficiency virus infection 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.
ANS: 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. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.
A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the "AIDS guy" and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the unit's nursing management. d. Tell the client that other staff members are talking about him or her.
ANS: A The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.
The nurse is caring for a client diagnosed with human immune deficiency virus. The client's CD4+ cell count is 399/mm3. 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 stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. 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 priority over stopping the spread of the disease.
A client has just been diagnosed with human immune deficiency virus (HIV). 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 should 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. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.
An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. "Truvada does not reduce the need for safe sex practices." b. "This drug has been taken off the market due to increases in cancer." c. "Truvada reduces the number of HIV tests you will need." d. "This drug is only used for postexposure prophylaxis."
ANS: A Truvada is a new drug used for pre-exposure 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 student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.
ANS: A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.
A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes
ANS: A, B, C, D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.
Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis 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
ANS: A, B, D 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 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.
A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L
ANS: A, D, E The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal.
A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should 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. Since this client's viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.
A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination
ANS: B Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should 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 acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities
ANS: B, C, D, E The UAP can assist the client with getting out of bed, obtain a bedside commode for the client's use, cleanse the client's perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.
A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (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.
ANS: B, C, E The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.
A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. "Gabapentin can be used as an antidepressant too." b. "I have no idea why you should be taking this drug." c. "This drug helps treat the pain from nerve irritation." d. "You are at risk for seizures due to fungal infections."
ANS: C Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.
A client with human immune deficiency virus 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 should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the 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 low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the 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.
A client with HIV 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 pounds/1 month
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.
A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the client's oxygen during activity. d. Pace activities, allowing for adequate rest
ANS: D This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client's activity.
An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.
ANS: D Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.
The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? A. Wearing gloves B. Wearing a gown and gloves C. Wearing a gown, gloves, and a mask D. Wearing a gown and gloves to change the bed linens, and gloves only for the bath
B. Wearing a gown and gloves Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.
The nurse is providing counseling to a woman who is HIV positive and has just discovered that she is pregnant. Which anti-HIV drug is given to HIV-infected pregnant women to prevent transmission of the virus to the infant? A. Acyclovir (Zovirax) B. Zidovudine (Retrovir) C. Ribavirin (Virazole) D. Foscarnet (Foscavir)
B. Zidovudine Zidovudine, along with various other antiretroviral drugs, is given to HIV-infected pregnant women and even to newborn babies to prevent maternal transmission of the virus to the infant. The other drugs are non-HIV antiviral drugs
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority? A. Altered nutrition, less than body requirements. B. Anticipatory grieving. C. Knowledge deficit, procedures and prognosis. D. Risk for injury.
D. Risk for injury. Safety is always an issue with the client with diminished mental capacity.
A patient is in the HIV clinic for a follow-up appointment. He has been on antiretroviral therapy for HIV for more than 3 years. The nurse will assess for which potential adverse effects of long-term antiretroviral therapy? (select all that apply). A. Lipodystrophy B. Liver damage C. Kaposi's sarcoma D. Osteoporosis E. Type 2 diabetes
A, B, D, E Anti-HIV drugs produce strain on the liver and may result in liver disease. A major adverse effect of protease inhibitors is lipid abnormalities, including lipodystrophy, or redistribution of fat stores under the skin. In addition, dyslipidemias, such as hypertriglyceridemia can occur, and insulin resistance and type 2 diabetes symptoms can result. The increase in long-term antiretroviral drug therapy due to prolonged disease survival has led to the emergence of another long-term adverse effect associated with these medications - bone demineralization and possible osteoporosis. Kaposi's sarcoma is an opportunistic disease associated with HIV, not a result of long-term drug therapy.
Which dietary change does the nurse suggest for the client who has diarrhea associated with HIV disease? A. "Avoid fatty foods." B. "Increase your intake of fiber." C. "Take an antacid 30 minutes before each meal." D. "Restrict your intake of fluids to 1 liter per day."
A. "Avoid fatty foods."
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? A. Assess the client's body weight and ask what the client has been able to eat. B. Place in contact isolation and don a mask and gown before entering the room. C. Check the HCP's orders and determine what laboratory tests will be done. D. Teach the client about total parenteral nutrition and monitor the subclavian IV site.
A. Assess the client's body weight and ask what the client has been able to eat. The client has a malnutrition syndrome. The nurse assesses the body and what the client has been able to eat.
The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? A. Flush the skin with water and try to get the area to bleed. B. Notify the charge nurse and complete an incident report. C. Report to the employee health nurse for prophylactic medication. D. Follow up with the infection control nurse to have laboratory work done.
A. Flush the skin with water and try to get the area to bleed. The nurse should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse. The nurse should notify the charge nurse after flushing the area and trying to get it to bleed. Reporting to the employee health nurse should be done within 4 hours of the exposure, not before trying to rid the body of the potential infection. Follow up with infection control is done at 3 months and 6 months after the initial exposure.
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? A. Protecting the client from infection B. Providing emotional support to decrease fear? C. Encouraging discussion about lifestyle changes. D. Identifying factors that decreased the immune function.
A. Protecting the client from infection The client with immunodeficiency had inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. The other options may be components of care but are not the priority.
The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? A. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. B. The HIV virus can be eradicated from the host body with the correct medical regimen. C. Is is difficult for the HIV virus to replicate in humans because it is a monkey virus. D. The HIV virus used the client's own red blood cells to reproduce the virus in the body.
A. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. Retroviruses never die; the virus may become dormant, only to be reactivated at a later time. "Eradicated" means to be completely cured or done away with; HIV cannot be eradicated. The HIV virus originated in the green monkey, in which it is not deadly. HIV in humans replicates readily using the CD4 cells as reservoirs. The HIV virus uses the CD4 cells of the immune system as reservoirs to replicate itself.
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? A. The client who has flushed, warm skin with tented turgor. B. The client who states the staff ignores the call light. C. The client whose vital signs are T 99.9˚F, P 101, R 26, and BP 110/68. D. The client who is unable to provide a sputum specimen.
A. The client who has flushed, warm skin with tented turgor. Flushed warm skin with tented turgor indicated dehydration. The HCP should be notified immediately for fluid orders or other orders to correct with reason for the dehydration. The temperature is slightly elevated and the pulse is one(1) beat higher than normal. Call light concerns can be addressed later after the client with physical concerns are addressed
A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the client's mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the client's abdomen.
ANS: A, C, D Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client's mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly
ANS: D All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.
The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first? A. Draw a serum for CD4 and complete blood count STAT. B. Administer oxygen to the client via nasal cannula. C. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB. D. Obtain a sputum specimen for culture and sensitivity.
B. Administer oxygen to the client via nasal cannula. Oxygen is a priority, especially with a client diagnosed with a respiratory illness.
Which couple has the highest risk for sexual transmission of HIV without the use of a condom or dental dam? A. uninfected male performing vaginal intercourse with an infected female B. Infected male performing vaginal intercourse with an uninfected female C. uninfected male performing anal intercourse with an infected male D. infected male performing oral sex on an uninfected male
B. Infected male performing vaginal intercourse with an uninfected female
The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? A. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush. B. Notify the HCP for an order for an antifungal swish-and-swallow medication. C. Have the client gargle with an antiseptic-based mouthwash several times a day. D. Determine what types of food the client has been eating for the last 24 hours.
B. Notify the HCP for an order for an antifungal swish-and-swallow medication This most likely is a fungal infection known as candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition.
The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members want to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation? A. Assign a different nurse every shift to the client. B. Ask the HCP to tell the client not to yell at the staff. C. Call a team meeting and discuss options with the staff. D. Tell one (1) staff member to care the client a week at a time.
C. Call a team meeting and discuss options with the staff. The health-care team should meet to discuss ways to best help the client deal with the anger being expressed, and the staff should be consistent in working with the client.
Which intervention in an important psychosocial consideration for the client diagnosed with AIDS? A. Perform a thorough head-to-toe assessment. B. Maintain the client's ideal body weight. C. Complete an advance directive. D. Increase the client's activity tolerance?
C. Complete an advance directive. Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS. Performing a head-to-toe assessment is a physiological intervention, not a psychosocial one. Maintaining body weight is physical. Activity tolerance is a physical problem.
During a health assessment, a 22-year old college student tells the nurse that she is sexually active and protects herself from HIV and other sexually transmitted diseases (STDs) by using oral contraceptives. What is the nurse's best action? A. Remind the student that only abstinence prevents STDs. B. Ask the health care provider to order an HIV test for this student. C. Inform the student that oral contraceptives protect against pregnancy but not against any STD. D. Reinforce the student's preferred use of oral contraceptives, and refrain from commenting on her sexual activity.
C. Inform the student that oral contraceptives protect against pregnancy but not against any STD.
The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Karposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? A. Swelling in the genital area. B. Swelling in the lower extremities. C. Positive punch biopsy of the cutaneous lesions. D. Appearance of reddish-blue lesions noted on the skin.
C. Positive punch biopsy of the cutaneous lesions. 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 and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of the cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.
The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? A. The client is fortunate not to have contracted HIV from an infected needle. B. The client must be repeatedly exposed to HIV before coming infected. C. The client may be in the primary infection phase of an HIV infection. D. The antibody test is negative because the client has a different flu virus.
C. The client may be in the primary infection phase of an HIV infection. The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV.
The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding AIDS should be included? A. Females taking birth control pills are protected from becoming infected with HIV. B. Protected sex is no longer an issue because there is a vaccine for the HIV virus. C. Adolescents with a normal immune system are not at risk for developing AIDS. D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.
D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV. Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship.
Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections? A. Contact Precautions. B. Airborne Precautions C. Droplet Precautions. D. Standard Precautions.
D. Standard Precautions. Standard precautions are used for all contact with blood and body secretions.
A client with acquired immunodeficiency syndrome (AIDS) and "Pneumocystis jiroveci" infection has been receiving pentamidine. The client develops a temperature of 101 F (38.3 C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition? A. The the dose of the medication is too low. B. That the client is experiencing toxic effects of the medication. C. That the client has developed inadequacy of thermoregulation. D. That the client has developed another infection caused by leukopenic effects of the medication.
D. That the client had developed another infection caused by leukopenic effects of the medication. Frequent adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection.
What is the most important question the nurse asks the client prescribed to begin highly active antiretroviral therapy? A. Do you have any symptoms now of active infection? B. Is there any possibility that you are pregnant? C. Are you currently sexually active? D. What other medications do you take?
D. What other medications do you take?
