Immune Disorders and HIV NCLEX Review

Which action must a nurse take first before drawing a blood sample for human immunodeficiency virus (HIV) testing? A. Tell the client that he'll be informed if the test results are positive. B. Inform the client that the sample is being obtained for routine testing. C. Make sure that an informed consent form has been signed. D, Put on gloves and a mask.

C. Make sure that an informed consent form has been signed. Before obtaining a sample for HIV testing, the nurse should make sure that an informed consent form has been signed. The nurse should explain why she is obtaining the sample — in this case, for HIV testing, not for routine testing. Gloves are necessary to obtain the sample. Eye protection should also be worn if splashing is likely. The client should be informed of the test results whether they are positive or negative.

A client with human immunodeficiency virus (HIV) experiences frequent bouts of diarrhea. The nurse determines dietary teaching is effective when the client states which food to avoid? A. red licorice B. broiled meat C. milk D. chicken soup

C. Milk Clients with chronic diarrhea may develop intolerance to lactose, which may worsen the diarrhea. Although red licorice (the candy) may be eaten, black licorice (the herb) should be avoided, as it may interfere with medications, especially corticosteroids. Other foods that the client should avoid include fatty foods, other lactose-containing foods, caffeine, and sugar. Chicken soup and broiled meat may be consumed.

Which action should the nurse take when a client diagnosed with human immunodeficiency virus (HIV) infection refuses treatment? A. Notify the physician, so he can have the client sign an Against Medical Advice form. B. Request that a family member speak with the client to insist that he be treated. C. Recommend that the client follow the treatment options presented by his physician. D. Recognize that the client might not be ready to make treatment decisions.

D. Recognize that the client might not be ready to make treatment decisions. The nurse should recognize that individuals may not be ready to make treatment decisions immediately after diagnosis. The nurse should make sure the client understands his treatment options but shouldn't make recommendations. The decision lies with the client. An Against Medical Advice form should be signed if the client insists on leaving the hospital against the advice of his physician. Requesting that a family member speak with the client breeches client confidentiality. Moreover, treatment decisions are for the client to make, not family members.

The nurse is meeting with a client who has recently been diagnosed with human immunodeficiency virus (HIV). The client is concerned about the impact of sharing the recent diagnosis with friends and family. What information can the nurse provide to the client? A. disclosing the diagnosis to social contacts may result in feelings of isolation B. sharing the diagnosis often causes friends and family to turn away C. there are few benefits of sharing the information with friends and family as long as one's health is stable D. sharing the diagnosis with friends and family members will provide a needed source of support

D. sharing the diagnosis with friends and family members will provide a needed source of support Studies support the benefit of sharing an HIV positive status with friends and family. This provides a source of support for the individual. Feelings of isolation may be heightened when the individual feels forced to live a double life and hide the truth of his HIV status. While the diagnosis of HIV may be difficult for friends and family to hear, it will allow them the opportunity of having increased openness and honesty in the relationship.

A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity? A. hiking in a forested area B. going horseback riding C. playing recreational softball D. swimming in rivers or lakes

D. swimming in rivers or lakes When a client with HIV has moved into the AIDS phase of the infection, the client has a very low CD4 count (<200) and is at high risk for opportunistic infections. One such infection is cryptosporidia, which is caused by protozoan parasites that are often found in water. Swimming in a river or lake greatly increases the risk of this exposure. While the client should take protection to avoid pathogens or injury during the other activities listed, none are known to carry a specific risk for the client that the nurse would need to emphasize compared to the risk of cryptosporidia infection from swimming in lakes or rivers.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should: A. maintain strict isolation. B. keep the client in a private room, if possible. C. wear gloves when providing mouth care. D. wear a gown when delivering the client's food tray.

D. wear gloves when providing mouth care. Standard precautions stipulate that a health care worker wear gloves when contact with a client's blood or other body fluids is anticipated, such as when providing mouth care. Maintaining strict isolation isn't needed because human immunodeficiency virus is spread by contact with contaminated blood or body fluids, which can be avoided by following standard precautions. A private room wouldn't provide barrier protection, which is needed for standard precautions. Wearing a gown is appropriate only when anticipating splashing of blood or body fluids.

A 27-year-old client with end-stage acquired immunodeficiency syndrome (AIDS) is being cared for by his wife at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about advance directives. At the next visit, the client states that since he and his wife filled out the advance directive form he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client 's concerns? A. "You don't need to feel that way. Your physician is required by law to sign your orders, and the hospice nurses will contact him with updates on your condition." B. "Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself." C. "Many people feel that way when they are admitted into hospice. Although the focus of your care has changed from curative to supportive, your physician will still continue directing it." D. "It's understandable to feel that way, but clients with end-stage AIDS who have advanced directives generally experience a less painful death than those individuals who don't."

"Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself." Option B provides correct information about advanced directives. The advanced directive outlines the client's treatment wishes should he be unable to communicate his wishes at any time during his illness. Option A invalidates the client's fears and doesn't emphasize the physician's continuing role or the client's role in his plan of care. Option C doesn't address the purpose of the advanced directive. Option D doesn't offer evidence-based information about advance directives.

A nurse is reinforcing the education plan with the parent of a 12-year-old child recently diagnosed with systemic juvenile arthritis (JA). Which statements by the parent best indicate that education has been effective? Select all that apply. 1. "Maintaining an appropriate, regular exercise program is very important." 2. "Systemic JA typically appears at or before the age of 12." 3. "High fevers that spike in the morning may be the first sign of the disease." 4. "It's important that my child's diet includes 1,300 mg of calcium daily." 5. "Warm showers in the morning may be very beneficial to easing my child's morning discomforts."

1, 4, 5 Maintaining a regular, appropriate exercise program is important to maintain muscle strength and joint flexibility. All types of JA occur at or before the age of 16. High fevers that spike at night and then suddenly disappear typically may be the first sign of systemic JA. It's important for a 12-year-old child to consume 1,300 mg of calcium daily to maintain bone health. Morning pain and stiffness are concerns of the child with juvenile arthritis. The longer a joint has been inactive the more discomfort that may be experienced. Heat related treatments are often effective in managing these concerns.

A 40-year-old client with mild dementia related to end-stage acquired immunodeficiency syndrome (AIDS) is preparing for discharge. She has decided against further curative treatment. Before discharge, she develops ocular cytomegalovirus (CMV). Her physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's husband feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which response best answers the husband's question while promoting client advocacy? A. "The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult." B. "The implant won't cure the virus in your wife's eye. The dementia she has means she is terminally ill. You're right to refuse further treatments because nothing more will help her." C. "The implant won't cure the virus, but it may protect her sight. Just because your wife has dementia, doesn't mean she shouldn't be given the opportunity to see." D. "The implant won't cure the virus. I'll tell the physician that you don't want her to have the procedure."

A. "The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult." By explaining the client's wishes while also promoting improved quality of life and safety for the client, the nurse is being the client's advocate. The other responses don't advocate for the client and may be considered confrontational.

A parent asks the clinic nurse how often the influenza virus vaccine should be given to a child. Which response would be most accurate? A. "The vaccine is usually given annually to children with certain risk factors." B. "I wouldn't worry; your child doesn't need the vaccine." C. "The vaccine is given monthly." D. "The vaccine is given every six months."

A. "The vaccine is usually given annually to children with certain risk factors." The influenza virus vaccine is usually administered annually to children at risk, not at monthly or 6-month intervals. The vaccine isn't contraindicated in children but is targeted at clients with chronic cardiac, pulmonary, hematologic, and neurologic problems.

How can a nurse best protect herself after she experiences a minor allergic reaction to latex? A. Avoid use of all latex products. B. Use latex products on a limited basis. C. Carry an allergic reaction kit. D. Avoid using latex gloves.

A. Avoid use of all latex products. After experiencing a latex allergy of any magnitude, the nurse must protect herself by avoiding all latex products. An allergic reaction kit won't prevent an allergic reaction from occurring.

Nurses were identified by the Centers for Disease Control and Prevention (CDC) as the people most likely to care for clients infected after the intentional release of the smallpox virus. Based on CDC guidelines, which group should volunteer to receive the smallpox vaccine? A. Nurses age 50 and older who work in the emergency departments of community hospitals. B. Nurses vaccinated against smallpox as children who are now working in a pediatric unit. C. Nurses who served in the military and are now working in public health settings. D. Nurses born after 1971 who are employed as triage nurses in large medical center emergency departments.

A. Nurses age 50 and older who work in the emergency departments of community hospitals. The CDC recommends the smallpox vaccine for nurses who received the vaccine as children (which includes those older than age 50) who work in the emergency department; emergency department nurses are most likely to care for those infected with the smallpox virus. Nurses born after 1971 weren't previously vaccinated against smallpox so the vaccine isn't currently recommended for those nurses. Military history doesn't dictate whether or not the vaccine is recommended. Nurses who work in the pediatric unit aren't at high risk for smallpox exposure; therefore, the vaccine isn't recommended for this group.

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which data collected by the nurse suggest that the decongestant has been effective? A. less sneezing B. clear nasal drainage C. increased tearing D. Headache

A. less sneezing Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants constrict blood vessels and reduce swelling in the nasal mucosa, permitting freer passage of air and secretions. Because decongestants alleviate congestion, they also relieve headaches, which can be caused by congestion. Clear nasal secretions and increased tearing are not evidence the decongestant is working.

During the recovery phase of a surgical client's hospitalization, a nurse notes that the client's immune status appears to be altered. Although there's no obvious rationale for the immunocompromise, which area should be further investigated? A. personal history of substance abuse or use B. nutrition C. family history of immune problems D. acquired immune disorder

A. personal history of substance abuse or use Substance abuse, including alcohol consumption and tobacco or marijuana use, influences immunocompetence and overall health status. Although nutrition is important for immunocompetence, it would be part of the client's daily assessment. A family history would have been assessed initially. Assessing the client for an acquired immune disorder would be a joint effort with the physician and wouldn't be conducted independently.

A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT), 200 mg by mouth every 4 hours. When teaching the client about this drug, the nurse should provide which instruction? A. "Take over-the-counter (OTC) drugs to treat minor adverse reactions." B. "Take zidovudine exactly as prescribed." C. "Take zidovudine on an empty stomach." D. "Take zidovudine with meals."

B. "Take zidovudine exactly as prescribed." To be effective, zidovudine must be taken exactly as prescribed. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the physician before taking OTC medications.

While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? A. guaifenesin B. diphenhydramine hydrochloride C. loperamide D. pseudoephedrine hydrochloride

B. diphenhydramine hydrochloride A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate? A. "If both sexual partners are HIV-positive, unprotected sex is permitted." B. "A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse." C. "Contraceptive methods, such as hormonal contraceptives, implants, and injections, are recommended for me to prevent HIV transmission." D. "The only safe sex my partner and I can practice is hugging, petting, and mutual masturbation."

B. 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. Safe sex practices include hugging, petting, mutual masturbation, and protected sexual intercourse. Abstinence is the most effective way to prevent transmission.

Which nursing intervention takes priority for a client with human immunodeficiency virus (HIV) infection? A. Encouraging consumption of a high-protein diet B. Protecting the client from infection C. Suggesting that the client speak with a social worker D. Administering pain medications, as prescribed

B. Protecting the client from infection Protecting the client from infection takes priority in the client with HIV infection. A high-protein diet isn't necessary unless the client's diet shows signs of protein deficiency. A consult with the social worker isn't necessary unless the client has financial concerns. Pain medication isn't needed unless the client experiences pain.

A child is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to chickenpox 1 week ago. When would this client require isolation if he or she were to remain hospitalized? A. 12 days after exposure B. immediate isolation is required C. 10 days after exposure D. isolation isn't required

B. immediate isolation is required The incubation period for chickenpox is 2 to 3 weeks, commonly 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of an earlier breakout. A person is infectious from 1 day before eruption of lesions until after the vesicles have formed crusts.

The parents of an infant report they are concerned about giving their child immunizations due to their association with autism. Which response by the nurse is appropriate? A. "There are limited risks of autism with the use of 'live' vaccines." \ B. "The use of inactivated vaccines has been linked to a slight increase in the development of autism in populations at risk." C. "Studies do not support a link between autism and immunizations." D. "The administration of more than one immunization at a time has shown a slight relationship with the development of autism."

C. "Studies do not support a link between autism and immunizations." There has been a great deal of discussion about the risk of autism being increased with the administration of immunizations. Studies do not presently show a correlation regardless of whether they are live or inactivated vaccines.

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information? A. Clients with autoimmune disorders may have false-negative but not false-positive serologic tests. B. Advanced medical intervention can cure most autoimmune disorders. C. Autoimmune disorders include connective tissue (collagen) disorders. D. Autoimmune disorders are distinctive, aiding differential diagnosis.

C. Autoimmune disorders include connective tissue (collagen) disorders. Connective tissue disorders are considered autoimmune disorders. Clients with autoimmune disorders may have either false-positive or false-negative serologic tests for syphilis. Other common laboratory findings in these clients include Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins. No cure exists for autoimmune disorders; treatment centers on controlling symptoms. Autoimmune disorders aren't distinctive; they share common features, making differential diagnosis difficult.

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of: A. beneficence. B. advocacy. C. autonomy. D. justice.

C. Autonomy Autonomy is the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence, promoting and doing good, and justice (being fair) aren't the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy.

A nurse is working with a support group for clients with human immunodeficiency virus (HIV). Which health promotion strategy should the nurse reinforce with the group? A. Understand the importance of using safer-sex practices. B. Tell potential sex partners about the diagnosis. C. Take antiretroviral medications as prescribed. D. Avoid the use of recreational drugs and alcohol.

C. Take antiretroviral medications as prescribed. It is essential for HIV infected clients to remain adherent with their antiretroviral therapy (ART) to suppress viral load and reduce the risk of transmitting HIV. Adherence with ART will help HIV infected clients to maintain their health. Clients with HIV should use safer-sex practices to prevent transmission of HIV and other sexually transmitted infections. Although it is helpful if clients with AIDS avoid using recreational drugs and alcohol to avoid virus transmission, it is more important that IV drug users use clean needles and dispose of used needles. Whether a client with AIDS chooses to tell potential sex partners about the diagnosis is the client's decision, unless the client is required to do so by law.

Which intervention does the nurse determine has the most impact in delaying the development of acquired immunodeficiency syndrome (AIDS) once a client has been infected with human immunodeficiency virus (HIV)? A. monthly plasmapheresis B. eating a diet of balanced, nutritious foods C. adherence with the complete therapeutic regimen D. getting adequate rest and sleep

C. adherence with the complete therapeutic regimen Compliance with the complete therapeutic regimen includes adhering to a healthy lifestyle, taking prescribed medications, and reducing risks from other infections. This is the most important intervention in delaying the onset of AIDS. Eating a balanced diet and getting adequate rest and sleep are part of the overall therapeutic regimen. Plasmapheresis isn't a treatment for HIV/AIDS.

A nurse is caring for a client with herpes zoster. The family is requesting to visit the client. Which action should the nurse take? A. allow the family to visit the client B. ask family members to wear a mask before entering the room C. instruct the family on contact precautions before they visit the client D. tell the family that the client is not allowed to have visitors

C. instruct the family on contact precautions before they visit the client Herpes zoster is a viral infection that is transmitted by direct contact. The family should not be allowed to visit without proper contact precautions. A mask is not required because this infection is neither an airborne or droplet infection.

How can a nurse best ensure the safety of a client who has a latex allergy? A. Inform the oncoming shift of the latex allergy during the shift report. B. Warn the client to avoid products containing latex. C. Make sure that the latex allergy is properly documented. D. Instruct the client to take antihistamines daily.

D. Make sure that the latex allergy is properly documented. The nurse should make sure that she properly documents the client's allergy to latex according to facility policy. She should then follow facility protocol for ensuring a latex-free environment for the client. The nurse shouldn't rely solely on verbal communication to inform the staff of the client's latex allergy. The client should be taught to avoid latex-containing products; however, the staff shouldn't rely on the client to make sure she avoids latex products. A physician's order is required for medication use, but daily antihistamine administration isn't necessary with latex allergy.

Which of the following is the most numerous type of white blood cell (WBC)? A. Lymphocyte B. Eosinophil C. Basophil D. Neutrophil

D. Neutrophil Neutrophils are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most abundant. Eosinophils account for about 2%, and basophils are the least abundant.

When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next? A. Rinse their eyes with water, record the incident on the client's chart, and see Employee Health. B. Wash their hands, complete an incident report, and see a physician as soon as possible. C. Rinse their eyes, contact Employee Health and document their findings. D. Rinse their eyes with water, report the incident, and go to Employee Health.

D. Rinse their eyes with water, report the incident, and go to Employee Health. Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush their eyes with water. The nurse should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse their may allow viral transmission through contact with the mucous membranes.

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

D. 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 caring for several client's with human immunodeficiency virus (HIV) infection. Which client does the nurse suspect has acquired immunodeficiency syndrome (AIDS) wasting syndrome? A. a client with oral pain, dysphagia, and yellow-white plaques in his mouth and throat B. a client with recurrent vaginitis causing intense itching and white, thick vaginal discharge C. a client with impaired memory, hallucinations, loss of balance, and personality changes D. a client who has lost 12% of her body weight, with weakness, fever, and chronic diarrhea for the past 35 days

D. a client who has lost 12% of her body weight, with weakness, fever, and chronic diarrhea for the past 35 days AIDS wasting syndrome is diagnosed when there's a loss of 10% or more of body weight and the presence of one or more of the following for more than 30 days: fever, weakness, and at least two loose stools daily. Oral pain with visible yellow-white plaques and vaginitis with a white, cottage cheese-like discharge suggest infection with Candida albicans. Impaired intellect and motor functioning indicate HIV infection of the central nervous system with AIDS dementia complex.

A nurse is caring for a client newly diagnosed with Human Immunodeficiency Virus (HIV). Which action by the nurse violates the client's confidentiality? A. sharing the client's information with the nursing assistant providing care to the client B. sharing the client's information with some of the nurses on the unit C. sharing the client's information with family members involved in the care of the client D. sharing the client's information with the clergy who is visiting with the client

D. sharing the client's information with the clergy who is visiting with the client The clergy has no direct involvement in the care of the client and therefore should have no knowledge of the client's information. Sharing client's information with anyone who is not directly involved with the care of the client violates confidentiality. Family members can only have access to client information after the client has authorized the health care agency to release such information. The nursing assistant who is caring for the client needs to know the client's status.