Ch. 36: Mgmt of Pts w/ Immune Deficiency Disorders

Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS? Liquids Gluten Sucrose Iron and zinc

Correct response: Liquids Explanation: The nurse should encourage clients with AIDS to consume liquids in order to help replace fluid and electrolyte losses. Gluten and sucrose may increase the complication of malabsorption. Large doses of iron and zinc should be avoided because they can impair immune function.

A nurse knows that more than 50% of clients with CVID develop the following disorder. Pernicious anemia Neutropenia Hypocalcemia Chronic diarrhea

Correct response: Pernicious anemia Explanation: More than 50% of clients with CVID develop pernicious anemia. Although chronic diarrhea may occur in clients with CVID, it does not happen in 50% of them. Hypocalcemia and neutropenia are not concerns for clients with CVID.

Telangiectasia is the term that refers to Vascular lesions caused by dilated blood vessels Inability to understand the spoken word Uncoordinated muscle movement Difficulty swallowing

Correct response: Vascular lesions caused by dilated blood vessels Explanation: Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia-telangiectasia is an autosomal-recessive disorder affecting both T-cell and B-cell immunity. Receptive aphasia is an inability to understand the spoken word. Dysphagia refers to difficulty swallowing.

A client taking fosamprenavir reports "getting fat." What is the nurse's best action? Have the client increase exercise. Assess the client's diet. Teach the client about medication side effects. Arrange for a psychological counseling.

Correct response: Teach the client about medication side effects. Explanation: The client needs to be aware of the potential for fat redistribution. Exercise, diet, and counseling will not change the outcome of this side effect.

Based on the nurse's base knowledge of primary immunodeficiencies, how would the nurse complete this statement? Primary immunodeficiencies develop early in life after protection from maternal antibodies decreases. occur most commonly in the aged population. develop as a result of treatment with antineoplastic agents. disappear with age.

Correct response: develop early in life after protection from maternal antibodies decreases. Explanation: These disorders may involve one or more components of the immune system. Primary immunodeficiencies are seen primarily in infants and young children. Primary immunodeficiencies are rare disorders with genetic origins. Without treatment, infants and children with these disorders seldom survive to adulthood.

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. semen urine breast milk blood vaginal secretions

Correct response: semen breast milk blood vaginal secretions Explanation: There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.

A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client take for the treatment of this infection? trimethoprim-sulfamethoxazole nystatin amphotericin B fluconazole

Correct response: trimethoprim-sulfamethoxazole Explanation: To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat candidiasis.

A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses. As part of the presentation, the nurse is planning to describe the events that occur once HIV enters the host cell. What would the nurse describe as the first step? Cleavage Budding Attachment Uncoating

Correct response: Attachment Explanation: Once HIV enters the host cell, attachment occurs in which the glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors. This is followed by uncoating, in which HIV's viral core is emptied into the CD4+ T cell. Cleavage and budding occur as the last steps.

Which blood test confirms the presence of antibodies to HIV? Erythrocyte sedimentation rate (ESR) p24 antigen Reverse transcriptase Enzyme immunoassay (EIA)

Correct response: Enzyme immunoassay (EIA) Explanation: EIA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.

A majority of clients with CVID develop which type of anemia? Hemolytic Pernicious Macrocytic Sickle cell

Correct response: Pernicious Explanation: A majority of clients with CVID develop pernicious anemia. They majority do not develop the other types of anemia listed.

The nurse is working with a parent whose child has just been diagnosed with selective immunoglobulin A deficiency. The parent asks the nurse, "Does this mean that my child is going to die?" How should the nurse respond? "Your child may die without proper medication and treatment." "Selective immunoglobulin A deficiency is the term used to describe the early stages of AIDS." "If left untreated, selective immunoglobulin A deficiency can cause uncontrolled muscle movements with progressive neurologic deterioration." "Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract."

Correct response: "Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract." Explanation: Selective immunoglobulin A deficiency is congenital and characterized by a lack of immunoglobulin A, which predisposes clients to recurrent infections, adverse reactions to blood transfusions or immunoglobulin, autoimmune diseases, and hypothyroidism. There is no current treatment.

The nurse practitioner who is monitoring the patient's progression of HIV is aware that the most debilitating gastrointestinal condition found in up to 90% of all AIDS patients is: Anorexia. Chronic diarrhea. Nausea and vomiting. Oral candida.

Correct response: Chronic diarrhea. Explanation: Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of AIDS can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive? Western Blot Schick Enzyme-linked immunosorbent assay (ELISA) Complete blood count (CBC)

Correct response: Enzyme-linked immunosorbent assay (ELISA) Explanation: The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. If the ELISA is positive twice then the Western Blot test is run. A CBC and a Schick test are not screening tests for HIV.

During a third-trimester transabdominal ultrasound, cardiac anomaly and facial abnormalities are noted in the fetus. Further testing reveals that the thymus gland has failed to develop normally, and the fetus is diagnosed with thymic hypoplasia. Based on this diagnosis, the nurse anticipates careful monitoring for which common manifestation during the first 24 hours of life? Hypoglycemia Hypocalcemia Hyperkalemia Thrombocytopenia

Correct response: Hypocalcemia Explanation: The most frequent presenting sign in clients with thymic hypoplasia (DiGeorge syndrome) is hypocalcemia that is resistant to standard therapy. It usually occurs within the first 24 hours of life.

A client is diagnosed with pneumocystis pneumonia (PCP). What medication does the nurse anticipate educating the client about for treatment? TMP-SMZ Cephalexin Azithromycin Garamycin

Correct response: TMP-SMZ Explanation: TMP-SMZ (Bactrim, Cotrim, Septra) is the treatment of choice for PCP; it is as effective as parenteral pentamidine isethionate (Pentacarinat) and more effective than other regimens.

A child has just been diagnosed with a primary immune deficiency. The parents state, "Oh, no. Our child has AIDS." Which response by the nurse would be most appropriate? "Your child does not have AIDS but this condition puts your child at risk for it later in life." "Your child's condition is extremely serious. Like AIDS, it will most likely be fatal." "Although AIDS is an immune deficiency, your child's condition is different from AIDS." "We need to do some more testing before we will know if your child's condition is AIDS."

Correct response: "Although AIDS is an immune deficiency, your child's condition is different from AIDS." Explanation: Primary immune deficiencies should be not be confused with AIDS. They are not the same condition. In addition, a primary immune disorder does not increase the child's risk for developing AIDS later in life. Primary immune deficiency diseases are serious, but they are rarely fatal and can be controlled. Testing will reveal the evidence of a primary immune disease, not AIDS. AIDS is classified as a seconary immunodeficiency.

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? "I will wash my hands whenever I get home from work." "I will make sure to have my own toothbrush and tube of toothpaste at home." "I will avoid contact with people who are sick or who have recently been vaccinated." "I will be sure to eat lots of fresh fruits and vegetables every day."

Correct response: "I will be sure to eat lots of fresh fruits and vegetables every day." Explanation: The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.

The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member? "The client probably has a case of the flu and you should give acetaminophen." "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." "This is one of the side effects from antiretroviral therapy and will require changing the medication." "The client probably has pneumocystis pneumonia and will need to be evaluated by the health care provider."

Correct response: "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." Explanation: A fungal infection, Cryptococcus neoformans is another common opportunistic infection among clients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures.

There are major differences between primary and secondary immunodeficiencies. Select the most accurate statement the nurse would use to explain the cause of a secondary immunodeficiency. "Your diagnosis was inherited." "Your condition will predispose you to frequent and recurring infections." "Your immune system was most likely affected by an underlying disease process." "You will now be more likely to develop cancer in the future."

Correct response: "Your immune system was most likely affected by an underlying disease process." Explanation: A secondary immunodeficiency is the result of an underlying disease process or the treatment of a disorder. It is not genetically inherited. Some examples of a secondary immunodeficiency are chronic stress and diabetes mellitus.

A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder? AIDS DAF CVID SCID

Correct response: AIDS Explanation: AIDS, the most common secondary disorder, is perhaps the best-known secondary immunodeficiency disorder. It results from infection with the human immunodeficiency virus (HIV). DAF refers to lysis of erythrocytes due to lack of decay-accelerating factor (DAF) on erythrocytes. CVID is a disorder that encompasses various defects ranging from IgA deficiency (in which only the plasma cells that produce IgA are absent) to severe panhypoglobulinemia (in which there is a general lack of immunoglobulins in the blood). Severe combined immunodeficiency disease (SCID) is a disorder in which both B and T cells are missing.

The nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care? Maintain the client in a supine or side-lying position. Encourage client to ambulate frequently in the halls. Assist with chest physiotherapy every 2 to 4 hours. Limit fluid intake to 1 1/2 to 2 liters per day.

Correct response: Assist with chest physiotherapy every 2 to 4 hours. Explanation: The nurse should include interventions such as assisting with and/or performing chest physiotherapy every 2 to 4 hours to prevent stasis of secretions, assist the client to attain the semi- or high Fowler's position to facilitate breathing and airway clearance, allow for frequent rest periods to prevent excessive fatigue, and maintain a fluid intake of at least 3 liters per day unless contraindicated.

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)? Bone marrow transplantation Antibiotics Radiation therapy Removal of the thymus gland

Correct response: Bone marrow transplantation Explanation: Treatment options for SCID include stem cell and bone marrow transplantation.

Which is usually the most important consideration in the decision to initiate antiretroviral therapy? CD4+ counts HIV RNA Western blotting assay ELISA

Correct response: CD4+ counts Explanation: The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts.

A client receiving atazanavir requires what priority intervention? Diet modification Cardiac assessment Renal function tests Increased fluids

Correct response: Cardiac assessment Explanation: This medication may cause prolongation of the PR interval and first-degree AV block. Clients with underlying conduction deficits may develop problems. A cardiac assessment will assist in determining whether the client has underlying problems that could be exacerbated by this drug therapy. The other interventions are not necessary.

A client with paroxysmal hemoglobinuria, a deficiency of complement proteins, reports headache and weakness of the right arm and leg. Based on these symptoms, for which health complication should the nurse assess? Rheumatoid arthritis Cerebral venous thrombosis Edema in subcutaneous tissues of the extremities Bacterial meningitis

Correct response: Cerebral venous thrombosis Explanation: Paroxysmal nocturnal hemoglobinuria is an acquired clonal stem cell disorder resulting from a somatic mutation in hematopoietic stem cells. Clinical manifestations may be indolent or life threatening. The disorder is characterized by hemoglobinuria that increases during sleep, as well as intravascular hemolysis, cytopenia, infections, bone marrow hyperplasia, and a high incidence of life-threatening venous thrombosis, which occurs most commonly in the abdominal and cerebral veins.

A nurse is monitoring the client's progression of human immunodeficiency virus (HIV). What debilitating gastrointestinal condition found in up to 90% of all AIDS clients should the nurse be aware of? Anorexia Chronic diarrhea Nausea and vomiting Oral candida

Correct response: Chronic diarrhea Explanation: Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of acquired immune deficiency syndrome (AIDS) can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.

A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority? Deficient knowledge related to the effects of the disease Risk for infection related to the immune system dysfunction Disturbed body image related to loss of fat in the face and arms Risk for impaired liver function related to drug therapy effects

Correct response: Disturbed body image related to loss of fat in the face and arms Explanation: The client is experiencing lipoatrophy, which results in a localized loss of subcutaneous fat in the face (manifested as sinking of the cheeks, eyes, and temples), arms, legs, and buttocks. These changes as well as his statement about the side effects of the drug being worse than the disease indicate that he is concerned about how he appears to others. Therefore, the nursing diagnosis of disturbed body image would be the priority. Deficient knowledge, risk for infection, and risk for impaired liver function may be applicable; however, they are not concerns at this time.

Which blood test confirms the presence of antibodies to HIV? Erythrocyte sedimentation rate (ESR) p24 antigen Reverse transcriptase Enzyme-linked immunosorbent assay (ELISA)

Correct response: Enzyme-linked immunosorbent assay (ELISA) Explanation: ELISA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. The p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.

A client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). The client undergoes biopsies of facial lesions and the preliminary report indicates Kaposi's sarcoma. Which action by the nurse is most appropriate? Pretend not to notice the lesions on the client's face. Tell the client that Kaposi's sarcoma is common in people with AIDS. Explore the client's feelings about facial disfigurement. Inform the client of the biopsy results and support the client emotionally.

Correct response: Explore the client's feelings about facial disfigurement. Explanation: The nurse should help the client explore his or her feelings about facial disfigurement because facial lesions can contribute to decreased self-esteem and an altered body image. Discussing AIDS with a client whose diagnosis isn't final may be inappropriate and doesn't provide emotional support. Pretending not to notice visible lesions ignores the client's concerns. The health care provider, not the nurse, should inform the client of the biopsy results.

A nurse is preparing to give a client an infusion of gamma globulin. The nurse knows to stop the infusion if the client experiences which symptoms? Select all that apply. Flank pain Shaking chills Tightness in the chest Hunger Fatigue

Correct response: Flank pain Shaking chills Tightness in the chest Explanation: Adverse reactions can include reports of flank and back pain, shaking chills, dyspnea, and tightness in the chest, as well as headache, fever, and local reaction at the infusion site.

A client with acquired immune deficiency syndrome (AIDS) is brought to the clinic by a family member. The family member tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms? Distal sensory polyneuropathy (DSP) Candidiasis HIV encephalopathy Cytomegalovirus (CMV)

Correct response: HIV encephalopathy Explanation: HIV encephalopathy, also called AIDS dementia complex or ADC, is a neurologic condition that causes the degeneration of the brain, especially in areas that affect mood, cognition, and motor functions. Such clients exhibit forgetfulness, limited attention span, decreased ability to concentrate, and delusional thinking. DSP is characterized by abnormal sensations, such as burning and numbness in the feet and later in the hands. Candidiasis is a yeast infection that may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in the folds of the skin. CMV infects the choroid and retinal layers of the eye, leading to blindness, and can also cause ulcers in the esophagus, colitis, diarrhea, pneumonia, and encephalitis.

When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic? means of transmission HIV-1 is more prevalent than HIV-2 subtypes the fact that it is a mutated virus originally thought to be bovine in nature cure rate

Correct response: HIV-1 is more prevalent than HIV-2 subtypes Explanation: Two HIV subtypes have been identified: HIV-1 and HIV-2. HIV-1 mutates easily and frequently, producing multiple substrains that are identified by letters from A through O. HIV-2 is less transmittable, and the interval between initial infection with HIV-2 and development of AIDS is longer. HIV-1 is more prevalent in the United States and in the rest of the world. Western Africa is the primary site of infection with HIV-2. There is no cure for HIV/AIDS; hence, no cure rate. The virus is thought to be a mutation of a simian virus. Transmission of the virus is not a characteristic.

Which condition is an early manifestation of HIV encephalopathy? Hyperreflexia Headache Vacant stare Hallucinations

Correct response: Headache Explanation: Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.

Which of the following indicates that a client with HIV has developed AIDS? Severe fatigue at night Pain on standing and walking Weight loss of 10 lb over 3 months Herpes simplex ulcer persisting for 2 months

Correct response: Herpes simplex ulcer persisting for 2 months Explanation: A diagnosis of AIDS cannot be made until the person with HIV meets case criteria established by the Centers for Disease Control and Prevention. The immune system becomes compromised. The CD4 T-cell count drops below 200 cells and develops one of the opportunistic diseases, such as Pneumocystis carinii pneumonia, candidiasis, cytomegalovirus, or herpes simplex.

A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find? Urine specific gravity of 1.010 Hypernatremia Hypokalemia Proteinuria

Correct response: Hypokalemia Explanation: Electrolyte imbalances such as decreased sodium, potassium, calcium, magnesium, and chloride typically result from profuse diarrhea. A urine specific gravity of 1.010 would indicate dilute urine. The client with severe diarrhea most likely would be dehydrated, leading to a high urine specific gravity. Proteinuria may suggest renal dysfunction and would not be associated with severe diarrhea unless the client was developing renal failure.

A patient in the clinic states, "My boyfriend told me he went to the clinic and was treated for gonorrhea." While testing for the sexually transmitted infection (STI), what else should be done for this patient? Test for HIV without informing the patient. Test for HIV, requiring the patient to sign a permit. Inform the patient that it would be beneficial to test for HIV. Administer treatment for the STI and discharge the patient.

Correct response: Inform the patient that it would be beneficial to test for HIV. Explanation: HIV screening is recommended for all persons who seek evaluation and treatment for STIs. HIV testing must be voluntary and free of coercion. Patients must not be tested without their knowledge. HIV screening after notifying the patient that an HIV test will be performed (unless the patient declines) is recommended in all health care settings. Specific signed consent for HIV testing should not be required. In most settings, general informed consent for medical care is considered sufficient.

HIV is harbored within which type of cell? Lymphocyte Platelet Erythrocyte Nerve

Correct response: Lymphocyte Explanation: Because HIV is harbored within lymphocytes, a type of white blood cell, any exposure to infected blood results in significant risk of infection. HIV infection is not harbored in platelets, erythrocytes, or nerve cells.

The nurse is aware that the most prevalent cause of immunodeficiency worldwide is Malnutrition Neutropenia Hypocalcemia Chronic diarrhea

Correct response: Malnutrition Explanation: The most prevalent cause of immunodeficiency worldwide is severe malnutrition.

Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment? Active substance abuse Depression Past substance abuse Lack of social support

Correct response: Past substance abuse Explanation: Factors associated with nonadherence include active substance abuse, depression, and lack of social support, as well as neurocognitive impairment, low health literacy, stressful life events, high levels of alcohol consumption, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment.

A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed? Gastric ulcer Pernicious anemia Hyperthyroidism Sickle cell anemia

Correct response: Pernicious anemia Explanation: More than 50% of clients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur.

A client is diagnosed with severe combined immunodficiency (SCID). What would the nurse expect to integrate into the client's plan of care? Administration of antifungal agents Preparation for bone marrow transplantation Administration of granulocyte colony-stimulating factors Preparation for a thymus graft

Correct response: Preparation for bone marrow transplantation Explanation: For a client with severe combined immunodeficiency (SCID), the nurse would include in the plan of care preparing the client for a bone transplant. Antifungal agents are used to treat chronic mucocutaneous candidiasis. Granulocyte-stimulating factors would be used to treat immunodeficiency related to phagocytic dysfunction. A thymus graft would be used to treat DiGeorge syndrome.

A client taking abacavir has developed fever and rash. What is the priority nursing action? Administer acetaminophen. Document the information. Report to the health care provider. Administer lidocaine cream for the rash.

Correct response: Report to the health care provider. Explanation: Fever and a rash could be indicative of a hypersensitivity reaction. Hypersensitivity reactions are also known as anaphylactic reactions and often involve skin rashes, fever, and bronchopulmonary issues such as bronchial constriction. The health care provider should be notified immediately and the medication stopped. Interventions need to be taken to assure that the client's airway is not compromised. Administering acetaminophen and documentation and treating the rash are not the priority and would be completed after the client is stabilized.

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy? Depression, memory impairment, and coma Respiratory or urinary system infections Rheumatoid arthritis Cardiac dysrhythmias and heart failure

Correct response: Respiratory or urinary system infections Explanation: Secondary immunodeficiencies occur as a result of underlying disease processes or the treatment of these disorders, including administration of immunosuppressive agents. Abnormalities of the immune system affect both natural and acquired immunity. Because immunodeficiencies result in a compromised immune system and pose a high risk for infection, careful assessment of the client's immune status is essential. The nurse assesses and monitors the client for signs and symptoms of infection.

A client with HIV will be started on a medication regimen of three medications. What drug will the nurse instruct the client about? Protease inhibitor Integrase inhibitors Reverse transcriptase inhibitors Hydroxyurea

Correct response: Reverse transcriptase inhibitors Explanation: Reverse transcriptase inhibitors are drugs that interfere with the virus' ability to make a genetic blueprint. A protease inhibitor is a drug that inhibits the ability of virus particles to leave the host cell. The integrase inhibitors are a class of drug that prevents the incorporation of viral DNA into the host cell's DNA. Hydroxyurea is a drug that is used as an adjunct therapy that tries to halt the progression of AIDS.

Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as containing the genetic viral material? Deoxyribonucleic acid (DNA) Ribonucleic acid (RNA) Viral core Glycoprotein envelope

Correct response: Ribonucleic acid (RNA) Explanation: HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? Bathing or hygiene self-care deficit Ineffective cerebral tissue perfusion Complicated grieving Risk for injury

Correct response: Risk for injury Explanation: In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.

A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions? Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens. Standard precautions should only be used with patients who are HIV positive to reduce the risk of transmission of the HIV virus. It is only necessary to use gloves when you are emptying reservoirs that have body fluids in them. If you are careful and do not expose yourself to blood or body fluids, it is not necessary to use gloves all of the time.

Correct response: Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens. Explanation: Standard precautions are designed to reduce the risk of transmission of bloodborne pathogens and of pathogens from moist body substances. Standard precautions are used when working with all patients in all health care settings, regardless of their diagnosis or presumed infectious status (Siegel, Rhinehart, Jackson, et al., 2007).

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis? Urine specimen for culture and sensitivity Blood specimen for electrolyte studies Stool specimen for ova and parasites Sputum specimen for acid fast bacillus

Correct response: Stool specimen for ova and parasites Explanation: A stool specimen for ova and parasites will give a definitive diagnosis. The organism is spread by the fecal-oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude of fluid quickly leads to dehydration and electrolyte imbalances.

The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm³, and the client has been diagnosed with pneumocystis pneumonia. What does this indicate to the nurse? The client has converted from HIV infection to AIDS. The client has advanced HIV infection. The client's T4-cell count has decreased due to the pneumocystis pneumonia. The client has another infection present that is causing a decrease in the T4-cell count.

Correct response: The client has converted from HIV infection to AIDS. Explanation: AIDS is the end stage of HIV infection. Certain events establish the conversion of HIV infection to AIDS: a markedly decreased T4 cell count from a normal level of 800 to 1200/mm³ and the development of certain cancers and opportunistic infections. The client does not have advanced HIV; they meet the criteria for the development of AIDS. The T4-cell count is not decreasing due to an infection.

A nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse demonstrates a need for a review of transmission routes by identifying which body fluid as a means of transmission? Urine Semen Blood Breast milk

Correct response: Urine Explanation: HIV is transmitted in body fluids that contain free virions and infected CD4+ T cells. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. Urine is not a body fluid responsible for HIV transmission.

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis? Thrombocytopenia Eczema Thrush Vascular lesions

Correct response: Vascular lesions Explanation: Ataxia-telangiectasis is characterized by loss of muscle coordination and vascular lesions. Thrombocytopenia and eczema are associated wtih Wiskott-Aldrich syndrome. Thrush is a manifestation associated with severe combined immunodeficiency (SCID).

A client has been diagnosed with HIV and has been placed on antiretroviral therapy. What does the nurse inform the client will be required for determining the progression of the disease as well as guiding drug therapy? The client will be required to stop the medication for 2 weeks and then have laboratory studies drawn to determine if the antiretroviral therapy has cured the disease. Viral load and T4-cell counts will be performed every 2 to 3 months. More antiretroviral medication will be added every 2 to 3 months. The Western blot test will be monitored every 6 months to see if the virus is still present.

Correct response: Viral load and T4-cell counts will be performed every 2 to 3 months. Explanation: Viral load testing is used to guide drug therapy and follow the progression of the disease. Viral load tests and T4-cell counts may be performed every 2 to 3 months once it is determined that a person is HIV positive. The medication should be adhered to and not discontinued. There is no cure for the disease at this time. Antiretroviral therapy is not generally changed or added to without reason or lack of response. The Western blot is used for confirmation of the presence of the HIV virus.

Which term defines the balance between the amount of HIV in the body and the immune response? Viral set point Window period Primary infection stage Viral clearance rate

Correct response: Viral set point Explanation: The viral set point is the amount of virus in the body after the initial immune response subsides is referred to as the viral set point, which results in an equilibrium between HIV levels and the immune response that may be elicited. During the primary infection period, the window period occurs because a person is infected with HIV but negative on the HIV antibody blood test. The period from infection with HIV to the development of antibodies to HIV is known as the primary infection stage. The amount of virus in circulation and the number of infected cells equals the rate of viral clearance.

A client with suspected human immunodeficiency virus (HIV) has had two positive enzyme-linked immunosorbent assay (ELISA) tests. What diagnostic test would be run next? ELISA Western Blot T4/T8 ratio Polymerase chain reaction

Correct response: Western Blot Explanation: The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. A positive result on Western blot confirms the diagnosis; however, false-positive and false-negative results on both tests are possible. A polymerase chain reaction gives the viral load of the client. The T4/T8 ratio determines the status of T lymphocytes.

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid: alcohol. applying skin moisturizers. seafood. exposure to sunlight.

Correct response: alcohol. Explanation: The nurse should advise a client taking antihistamines not to take it with alcohol or other central nervous system depressants because additive sedative effects can occur.

Kaposi sarcoma (KS) is diagnosed through skin scraping. biopsy. visual assessment. computed tomography.

Correct response: biopsy. Explanation: KS is diagnosed through biopsy of the suspected lesions. Visual assessment will not confirm a diagnosis. A computed tomography scan will not assist in determining skin cell changes. Skin scraping is a procedure to collect cells, not to evaluate cells.

A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wartlike lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding? testing the client for the presence of HIV instructing the client to wear cotton underwear having the client abstain from sexual activity for 6 weeks while the medication is working using a medicated douche in order to keep the vaginal pH normal

Correct response: testing the client for the presence of HIV Explanation: Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may correlate with HIV infection. Wearing cotton underwear can help with the prevention of candidiasis but does not address the recurrent vaginal infection that may not be caused by a fungus. Abstaining from sexual intercourse does not address the recurrent vaginal infection. A medicated douche can alter the normal flora of the vaginal wall.

The majority of patient with primary immunodeficiency are in which age group? Younger than 20 20 to 40 41 to 50 51 to 60

Correct response: Younger than 20 Explanation: About 80% of the patients with primary immunodeficiency are younger than age 20 years.

The lower the client's viral load, the shorter the time to AIDS diagnosis. the longer the survival time. the shorter the survival time. the longer the time immunity.

Correct response: the longer the survival time. Explanation: The lower the client's viral load, the longer the time to AIDS diagnosis and the longer the survival time. The key goal of antiretrovial therapy is to achieve and maintain durable viral suppression.