Immune Deficiencty
(REVIEW) Which of the following indicates that a client with HIV has developed AIDS? Herpes simplex ulcer persisting for 2 months Weight loss of 10 lb over 3 months Severe fatigue at night Pain on standing and walking
Herpes simplex ulcer persisting for 2 months 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 on antiretroviral drug therapy informs the nurse about sometimes forgetting to take the medication for a few days. What should the nurse inform the client can occur when the medications are not taken as prescribed? The client will have to take higher doses of the antiviral medications. The client will have to take the drugs intravenously to ensure compliance. The client is risking the development of drug resistance and drug failure. The funding for the medications will cease if the client is not taking the meds correctly.
The client is risking the development of drug resistance and drug failure. Clients who neglect to take antiretroviral drugs as prescribed risk development of drug resistance. When drug levels are not adequately maintained, viral replication and mutations increase. Funding will not cease for noncompliance. The medications are not all available in IV form. Taking a higher dose of the medication if missed does not resolve drug resistance.
(REVIEW) A client who is HIV positive has been prescribed antiretroviral drugs. The nurse explains the action of each antiretroviral drug and develops a schedule for the client's self-administration, including strong emphasis about rigidly adhering to the dosage, time and frequency of the administration of the drugs. Why is it important to adhere to the schedule of drug dosing developed for this client? To avoid resistance to the drugs To avoid overdosing on the drugs To maintain appropriate blood levels of the drugs To get the most benefit from the drugs
To avoid resistance to the drugs For clients with an established HIV status, the nurse explains the action of each antiretroviral drug and develops a schedule for the client's self-administration. This includes strong precautions about rigidly adhering to the dosage, time, and frequency of drug administration to avoid resistance. Adhering rigidly to the developed schedule is not to preclude overdosing, or to maintain appropriate blood levels, or to get the most benefit from the drugs.
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. "You will now be more likely to develop cancer in the future." "Your immune system was most likely affected by an underlying disease process." "Your condition will predispose you to frequent and recurring infections." "Your diagnosis was inherited."
"Your immune system was most likely affected by an underlying disease process." 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.
Which condition is an early manifestation of HIV encephalopathy? Vacant stare Hallucinations Hyperreflexia Headache
Headache 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.
While caring for a patient with pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate? Seborrheic dermatitis Kaposi's sarcoma Molluscum contagiosum Tuberculosis of the skin
Kaposi's sarcoma Kaposi's sarcoma, the most common HIV-related malignancy, is a disease that involves the endothelial layer of blood and lymphatic vessels. Cutaneous signs may be the first manifestation of HIV; they can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymoses (hemorrhagic patches) and edema (Fig. 37-3).
A client is infected with human immunodeficiency virus (HIV) after sharing needles with another intravenous (IV) drug abuser. Upon infection with HIV, the immune system responds by making antibodies against the virus, usually within how many weeks after infection? 6 to 18 weeks 3 to 12 weeks 3 to 6 weeks 1 to 2 weeks
3 to 12 weeks When a person is infected with HIV, the immune system responds by producing antibodies against the virus, usually within 3 to 12 weeks after infection.
A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time? 6 weeks 12 weeks 18 weeks 24 weeks
6 weeks Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels.
(REVIEW) 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 (ENLARGEMENT) of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed? Hyperthyroidism Sickle cell anemia Gastric ulcer Pernicious anemia
Pernicious anemia 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.
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: Nausea and vomiting. Chronic diarrhea. Anorexia. Oral candida.
Chronic diarrhea. 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.
More than 50% of individuals with this disease develop pernicious anemia: Common variable immunodeficiency (CVID) Bruton disease Nezelof syndrome DiGeorge syndrome
Common variable immunodeficiency (CVID) More than 50% of clients with CVID develop pernicious anemia. Pernicious anemia is not associated with the other conditions.
(REVIEW) Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment? Past substance abuse Lack of social support Depression Active substance abuse
Past substance abuse 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.
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS? Gluten Sucrose Liquids Iron and zinc
Liquids 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.
(REVIEW) The nurse teaches the client that reducing the viral load will have what effect? Shorter survival Longer survival Longer immunity Shorter time to AIDS diagnosis
Longer survival The lower the client's viral load, the longer the survival time and the longer the time to AIDS diagnosis.
A client taking fosamprenavir reports "getting fat." What is the nurse's best action? Arrange for a psychological counseling. Teach the client about medication side effects. Have the client increase exercise. Assess the client's diet.
Teach the client about medication side effects. 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.
A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate? Contraceptive methods, such as hormonal contraceptives, implants, and injections, are recommended to prevent HIV transmission. The intrauterine device is recommended for a client with HIV. If the client and her sexual partners are HIV-positive, unprotected sex is permitted. A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.
A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. The nurse should caution the client not to have unprotected sex because continued exposure to HIV in a seropositive client may hasten the course of the disease or result in infection with another strain of HIV. Hormonal contraceptives, implants, and injections offer no protection against HIV transmission. The intrauterine device isn't recommended for a client with HIV because it may increase her susceptibility to pelvic inflammatory disease.
A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching? Caregiver uses a dilute bleach solution to clean up a urine spill. Caregiver disposes of syringe and needle in a metal coffee can with lid. Caregiver cleans the client's anal area without wearing gloves Caregiver washes hands before and after providing care to the client.
Caregiver cleans the client's anal area without wearing gloves To prevent the risk of HIV transmission, standard precautions should be used. Cleaning the client's anal area without wearing gloves indicates that the nurse needs to reinstruct the caregiver in measures related to standard precautions. Handwashing before and after client care, disposing of sharps in a puncture-resistant container, and cleaning up spills with a dilute bleach solution are appropriate measures.
A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize what intervention? Screening programs for youth and young adults Appropriate use of standard precautions Educational programs that focus on control and prevention Lifestyle actions that improve immune function
Educational programs that focus on control and prevention Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions applies to very few cases of HIV infection.
Which blood test confirms the presence of antibodies to HIV? Reverse transcriptase p24 antigen Erythrocyte sedimentation rate (ESR) Enzyme-linked immunosorbent assay (ELISA)
Enzyme-linked immunosorbent assay (ELISA) 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 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? Complete blood count (CBC) Western Blot Enzyme-linked immunosorbent assay (ELISA) Schick
Enzyme-linked immunosorbent assay (ELISA) 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.
(REVIEW) Students are reviewing information from the Centers for Disease Control and Prevention (CDC) for a class presentation about preventing the transmission of HIV. Which of the following would the students be least likely to include in their presentation? A dental dam is used for oral contact with the vagina or rectum. Male condoms must be used consistently and correctly to be effective. Nonlatex lambskin condoms are highly effective in preventing HIV infection. Circumcision is an effective means to reduce the risk of males acquiring HIV.
Nonlatex lambskin condoms are highly effective in preventing HIV infection. Condoms, if used correctly and consistently, are highly effective in preventing HIV. Nonlatex condoms made from natural materials, such as lambskin, do not protect against HIV infection. Dental dams should be used for oral contact with the vagina or rectum. In 2007, the World Health Organization and UNAIDS recommended that circumcision be recognized as an effective strategy to reduce the risk of HIV acquisition in men.
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 the form of the genetic viral material? Deoxyribonucleic acid (DNA) Ribonucleic acid (RNA) Glycoprotein envelope Viral core
Ribonucleic acid (RNA) 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 Risk for injury Complicated grieving Ineffective cerebral tissue perfusion
Risk for injury 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 nurse is implementing appropriate infection control precautions for a client who is positive for human immunodeficiency virus (HIV). The nurse knows which body fluid is not a means of transmission? Breast milk Blood Urine Semen
Urine 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.
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: p24 antigen test for confirmation of diagnosis. Western blot test for confirmation of diagnosis. polymerase chain reaction test for confirmation of diagnosis. T4-cell count for confirmation of diagnosis.
Western blot test for confirmation of diagnosis. The enzyme-linked immunosorbent assay (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. The p24 antigen test and the polymerase chain reaction test determine the viral load. The T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.
(REVIEW) 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.
alcohol 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.
A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate? Kaposi's sarcoma hairy leukoplakia coccidioidomycosis candidiasis
candidiasis Candidiasis is a yeast infection caused by the Candida albicans microorganisms. It may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in folds of the skin. It is often called thrush when located in the mouth. Inspection of the mouth, throat, or vagina reveals areas of white plaque that may bleed when mobilized with a cotton-tipped swab. Kaposi's sarcoma is a purple lesion and is an opportunistic cancer. Hairy leukoplakia is also an indication of oral cancer. Coccidioidomycosis causes diarrhea in the immunosuppressed client.
Based on the nurse's base knowledge of primary immunodeficiencies, how would the nurse complete this statement? Primary immunodeficiencies develop as a result of treatment with antineoplastic agents. disappear with age. develop early in life after protection from maternal antibodies decreases. occur most commonly in the aged population.
develop early in life after protection from maternal antibodies decreases. 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.
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? "We need to do some more testing before we will know if your child's condition is AIDS." "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."
"Although AIDS is an immune deficiency, your child's condition is different from AIDS." 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 secondary immunodeficiency.
A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? "It doesn't matter if you take this drug with or without food." "Be sure to take this drug about 1/2 hour before or 2 hours after you eat." "You should take the drug with an antacid." "When you take this drug, eat a high-fat meal immediately afterwards."
"Be sure to take this drug about 1/2 hour before or 2 hours after you eat." Didanosine (Videx) should be taken 30 to 60 minutes before or 2 hours after meals. Other antiretroviral agents, such as abacavir, emtricitabine, or lamivudine can be taken without regard to meals. High-fat meals should be avoided when taking amprenavir. Atazanavir should be taken with food and not with antacids.
A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? "I won't go to see my nephew right after he gets his vaccines." "I can eat whatever I want as long as it's low in fat." "I stopped smoking last year; this year I'll quit drinking alcohol." "I won't go to see my sister while she has a cold."
"I can eat whatever I want as long as it's low in fat." The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client.
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 be sure to eat lots of fresh fruits and vegetables every day." "I will avoid contact with people who are sick or who have recently been vaccinated." "I will make sure to have my own toothbrush and tube of toothpaste at home." "I will wash my hands whenever I get home from work."
"I will be sure to eat lots of fresh fruits and vegetables every day." 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.
A client with AIDS has become forgetful with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms? AIDS dementia complex (ADC) cytomegalovirus (CMV) distal sensory polyneuropathy (DSP) candidiasis
AIDS dementia complex (ADC) ADC, a neurologic condition, 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 assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following? He has not been infected with HIV. Antibodies to HIV are present in his blood. He is immune to HIV. Antibodies to HIV are not present in his blood.
Antibodies to HIV are not present in his blood. A negative test result indicates that antibodies to HIV are not present in the blood at the time the blood sample for the test is drawn. A negative test result should be interpreted as demonstrating that if infected, the body has not produced antibodies (which take from 3 weeks to 6 months or longer). Therefore, subsequent testing of an at-risk patient must be encouraged. The test result does not mean that the patient is immune to the virus, nor does it mean that the patient is not infected. It just means that the body may not have produced antibodies yet. When antibodies to HIV are detected in the blood, the test is interpreted as positive.
A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses, including the steps in the process of HIV entering the host cell. What would the nurse describe as the first step? Uncoating Budding Cleavage Attachment
Attachment 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.
A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise? Avoid fibrous foods, lactose, fat, and caffeine. Reduce food intake. Increase intake of iron and zinc. Consume large, high-fat meals.
Avoid fibrous foods, lactose, fat, and caffeine. Diarrhea may subside when the client avoids fibrous foods, lactose, fat, and caffeine. Although eating may seem to cause diarrhea, the client must understand that limiting the intake of food to control diarrhea only exacerbates wasting. The client will tolerate a low-fat, high-carbohydrate, and soft or liquid diet better than large, high-fat meals. The client should be advised to avoid large doses of iron and zinc because they can impair the functioning of the immune system.
A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included? Be alert for signs and symptoms of infection and report them immediately to the physician. This medication is commonly used for many inflammatory reactions and is relatively safe. The client should be alert for joint aches. If the client experiences nausea, omit the dose.
Be alert for signs and symptoms of infection and report them immediately to the physician. Instruct the client about signs and symptoms of and the increased risk for infection. Instruct the client to report signs and symptoms of infection immediately to the physician. Early treatment promotes a shorter duration of illness and reduced complication. Tell the client to avoid high-risk activities, such as being in crowds, during periods of immunosuppression. The client should not omit a dose if nausea is experienced; he may take the medication with food. There are many side effects and required laboratory work to detect the side effects from immunosuppressive therapy. Joint aches are vague symptoms and are not a priority for reporting purposes.
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? Risk for impaired liver function related to drug therapy effects Deficient knowledge related to the effects of the disease Disturbed body image related to loss of fat in the face and arms Risk for infection related to the immune system dysfunction
Disturbed body image related to loss of fat in the face and arms 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.
(REVIEW) A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." Which nursing action is the priority for this client? Provide a prescribed topical antifungal agent to treat the client's vaginal infection. Recommend abstinence or safer-sex practices. Refer the client to a support group with others experiencing the same symptoms. Offer information on human immunodeficiency virus (HIV) testing.
Offer information on human immunodeficiency virus (HIV) testing. In women, gynecologic problems may be the focus of the chief complaint for clients who are HIV positive but not yet diagnosed. Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may also correlate with HIV infection. Based on this information, the priority nursing action is to offer information on HIV testing to the client. Although recommending abstinence or safer-sex practices, providing a prescribed topical antifungal agent to treat the client's vaginal infection, and referring to a support group may be appropriate, the priority is to determine the source of the client's symptoms.
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits what behavior? The nurse wears face protection, gloves, and a gown when irrigating a wound. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. The nurse performs hand hygiene with a waterless antiseptic agent after removing a pair of soiled gloves.
The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure. Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same client. Each of the other listed actions adheres to standard precautions.