Ch 32: Management of Patients with Immune Deficiency Disorders

a) Viral load Pg. 1007 Viral load should be measured at baseline and on a regular basis thereafter because viral load is the most important indicator of response to ART. The other tests are not used in this way.

29. What test will the nurse assess to determine the client's response to antiretroviral therapy? a) Viral load b) Complete blood count c) Enzyme immunoassay d) Western blotting

d) Enzyme-linked immunosorbent assay (ELISA) Pg. 1007 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.

3. 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? a) Schick b) Western Blot c) Complete blood count (CBC) d) Enzyme-linked immunosorbent assay (ELISA)

d) Alcohol Pg. 1033 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.

16. A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid: a) Exposure to sunlight b) Seafood c) Applying skin moisturizers d) Alcohol

c) "Any change, however subtle, might mean that I have an infection" Pg. 1024 For clients with immunodeficiencies, subtle changes may indicate an infection. Therefore, the client would contact the health care provider if symptoms develop that are not typical. Fever does not need to be over 101 degrees to indicate an infection. A cough, either dry or wet, or swollen lymph nodes suggest infection.

21. A nurse is teaching a client with immunodeficiency about the signs and symptoms of infection to report. The nurse determines that the teaching was successful when the client makes which statement? a) "A dry cough is just irritation, but one with mucous means an infection" b) "A fever over 101 degrees is the most common sign of infection" c) "Any change, however subtle, might mean that I have an infection" d) "I might notice a swollen lymph node or two, but this is normal"

d) Chronic diarrhea Pg. 1022 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.

24. 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: a) Oral candida b) Nausea and vomiting c) Anorexia d) Chronic diarrhea

d) CDC stage 1: Acute HIV infection Pg. 1013 In a person aged 6 to adult, more than 500 CD4+ T lymphocytes/mm3 indicates CDC stage 1: Acute HIV infection. If there is a negative HIV test within 6 months of the diagnosis of HIV that is CDC stage 0. A count of 200 to 499 CD4+ T lymphocytes/mm3 indicates CDC stage 2: Clinical latency (HIV inactivity or dormancy). Less than 200 CD4+ T lymphocytes/mm3 indicates CDC stage 3: Acquired immunodeficiency syndrome (AIDS).

27. In an adult client, which stage of HIV infection is indicated when the results are more than 500 CD4+ lymphocytes/mm? a) CDC stage 0: Early infection b) CDC stage 2: Clinical latency (HIV inactivity or dormancy) c) CDC stage 3: Acquired immunodeficiency syndrome (AIDS) d) CDC stage 1: Acute HIV infection

a) Preparation for bone marrow transplantation Pg. 1006 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.

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

a) 10:30 to 11:00 a.m. Pg. 1007 When administering IVIG, anaphylactic reactions typically occur 30 to 60 minutes after the start of the infusion. Therefore, the time frame would be 10:30 to 11:00 a.m.

36. A client is to receive intravenous immunoglobulin (IVIG). The infusion is started at 10 a.m. The nurse would be alert for signs and symptoms of an anaphylactic reaction during which time frame? a) 10:30 to 11:00 a.m. b) 11:00 to 11:30 a.m. c) 11:30 a.m. to 12:00 p.m. d) 12:30 p.m. to 1:30 p.m.

b) Biopsy Pg. 1022 KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count.

10. Kaposi sarcoma (KS) is diagnosed through a) Skin scraping b) Biopsy c) Visual assessment d) Computed tomography

c) Increased susceptibility to infection Pg. The complement system is an integral part of the immune system, and deficiencies in normal levels of complement result in increased susceptibility to infectious diseases and immune-mediated disorders.

2. What does the nurse understand will result if the patient has a deficiency in the normal level of complement? a) Development of congestive heart failure b) Decrease in vascularity to the extremities c) Increased susceptibility to infection d) Risk of stroke

a) "Your immune system was most likely affected by an underlying disease process" Pg. 1005 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.

33. 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. a) "Your immune system was most likely affected by an underlying disease process" b) "You will now be more likely to develop cancer in the future" c) "Your diagnosis was inherited" d) "Your condition will predispose you to frequent and recurring infections"

d) Pneumocystis jiroveci Pg. 1021 Although mycobacterium, legionella, and cytomegalovirus may cause the signs and symptoms described, the most common infection in people with AIDS is pneumocystis pneumonia caused by pneumocystis jiroveci. It is the most common opportunistic infection associated with AIDS.

7. A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect? a) Cytomegalovirus b) Legionella c) Mycobacterium avium complex d) Pneumocystis jiroveci

c) Assist with chest physiotherapy every 2 to 4 hours Pg. 1028 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.

14. 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? a) Limit fluid intake to 1 1/2 to 2 liters per day b) Encourage client to ambulate frequently in the halls c) Assist with chest physiotherapy every 2 to 4 hours d) Maintain the client in a supine or side-lying position

a) Report the incident to the supervisor Pg. 1012 Because post exposure protocols can reduce the risk of HIV infection if initiated promptly, nurses must immediately report any needlestick or sharp injury to a supervisor. Obtaining counseling will occur after all other procedures are adhered to. The lab will draw blood from the client if required for documentation and other blood transmitted disorders.

22. The nurse administers an injection to a client with AIDS. When finished, the nurse attempts to recap the needle and sustains a needlestick to the finger. What is the priority action by the nurse? a) Report the incident to the supervisor b) Fill out a risk management report c) Obtain counseling d) Call the lab to draw the nurse's blood

d) Urine Pg. 1009 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.

26. 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? a) Blood b) Semen c) Breast milk d) Urine

a) Shaking chills c) Flank pain e) Tightness in the chest Pg. 1006 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.

11. 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. a) Shaking chills b) Hunger c) Flank pain d) Fatigue e) Tightness in the chest

d) Pneumocystis pneumonia Pg. 1021 Pneumocystic pneumonia (PCP) is one of the first and most common opportunistic infections associated with AIDS. It may be present despite the absence of crackles. If untreated, PCP progresses to cause significant pulmonary impairment and respiratory failure.

6. The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurrence) in persons with AIDS? a) Mycobacterium tuberculosis b) Cytomegalovirus c) Legionnaire's disease d) Pneumocystis pneumonia

b) AIDS dementia complex (ADC) Pg. 1023 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.

12. 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? a) Candidiasis b) AIDS dementia complex (ADC) c) Cytomegalovirus (CMV) d) Distal sensory polyneuropathy (DSP)

a) Uncoordinated muscle movement Pg. 1023 Ataxia-telangiectasia is an autosomal recessive disorder affecting both T-cell and B-cell immunity. Telangiectasia refers to vascular lesions caused by dilated blood vessels. Receptive aphasia is an inability to understand spoken words. Dysphagia refers to difficulty swallowing.

8. Ataxia refers to a) Uncoordinated muscle movement b) Difficulty swallowing c) Vascular lesions caused by dilated blood vessels d) Inability to understand spoken words

a) HIV-1 is more prevalent than HIV-2 subtypes Pg. 1013 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.

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

a) Side effects of drug therapy Pg. 1031 Describing the side effects of drug therapy is essential, with the admonition to refrain from discontinuing any of the prescribed drugs without first consulting the prescribing physician. Although the client may want to know how the drugs work in general, the specific action of each antiretroviral drug is not essential information. Teaching about condoms and vaccinations may be appropriate, but these topics are not directly related to the client's HIV medications.

13. The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications? a) Side effects of drug therapy b) What vaccinations to have c) The use of condoms d) The action of each antiretroviral drug

c) Lymphocyte Pg. 1013 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.

15. HIV is harbored within which type of cell? a) Erythrocyte b) Nerve c) Lymphocyte d) Platelet

a) Western blot assay Pg. 1033 A positive EIA test indicates seropositivity. To confirm this, a Western blot assay would be done. The OraSure test uses saliva to perform an EIA test. The p24 antigen test and nucleic acid sequence-based amplification test are used to test viral load and evaluate response to treatment. However, the reverse transcriptase-polymerase chain reaction (RT-PCR) and nucleic acid sequence-based tests have replaced the p24 antigen test. The RT-PCR tests may be used to confirm a positive EIA result.

17. A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test? a) Western blot assay b) p24 antigen capture assay c) Nucleic acid sequence-based amplification d) OraSure test

c) Develop early in life after protection from maternal antibodies decreases Pg. 1013 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.

18. Based on the nurse's base knowledge of primary immunodeficiencies, how would the nurse complete this statement? Primary immunodeficiencies a) Develop as a result of treatment with antineoplastic agents b) Occur most commonly in the aged population c) Develop early in life after protection from maternal antibodies decreases d) Disappear with age

d) "Although AIDS is an immune deficiency, your child's condition is different from AIDS" Pg. 1005 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.

19. 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? a) "Your child does not have AIDS but this condition puts your child at risk for it later in life" b) "Your child's condition is extremely serious. Like AIDS, it will most likely be fatal" c) "We need to do some more testing before we will know if your child's condition is AIDS" d) "Although AIDS is an immune deficiency, your child's condition is different from AIDS"

c) HIV encephalopathy Pg. 1023 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.

20. 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? a) Distal sensory polyneuropathy (DSP) b) Cytomegalovirus (CMV) c) HIV encephalopathy d) Candidiasis

a) Report to the health care provider Pg. 1018 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.

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

c) The client may be in stage 0 of the disease Pg. 1015 There are three types of HIV diagnostic tests: antibody tests, antigen/antibody tests, and nucleic acid (RNA) tests. Antibody tests detect antibodies, not HIV itself, while antigen and RNA tests directly detect HIV. The CDC recommends tests for HIV antigens and HIV nucleic acid because studies from high risk populations found that antibody testing alone might miss a considerable percentage of HIV infections detectable by virologic tests, especially during stage 0. The antibody test for HIV is sensitive and specific to antibodies but other tests should be performed for a definitive diagnosis. The client does not need an additional test because of engaging in high risk behavior. Two tests are not mandatory for every client.

25. A client's antibody test for HIV showed no antibodies. For which reason would the client need to have a nucleic acid test completed before being told that testing for HIV is negative? a) The client engages in high risk behavior b) Two tests need to be done for every client c) The client may be in stage 0 of the disease d) The antibody test for HIV is not sensitive

b) Assess blood urea nitrogen and creatinine Pg. 1026 Adverse effects associated with antiretroviral therapy include potential nephrotoxicity. Assessing blood urea nitrogen and creatinine for clients who have decreased urination is appropriate. The other answers will not assist the nurse in determining the client's problem, which should be assessed before intervention are administered.

28. A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action? a) Assess liver function tests b) Assess blood urea nitrogen and creatinine c) Administer fluids 100 mL/hour IV d) Encourage the client to drink more fluids

d) Disturbed body image related to loss of fat in the face and arms Pg. 1016 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.

30. 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? a) Deficient knowledge related to the effects of the disease b) Risk for impaired liver function related to drug therapy effects c) Risk for infection related to the immune system dysfunction d) Disturbed body image related to loss of fat in the face and arms

a) "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider" Pg. 1024 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.

31. 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? a) "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider" b) "The client probably has a case of the flu and you should give acetaminophen" c) "This is one of the side effects from antiretroviral therapy and will require changing the medication" d) "The client probably has pneumocystis pneumonia and will need to be evaluated by the health care provider"

c) Disclosure of the client's condition Pg. 1034 Despite HIV-specific confidentiality laws, clients infected with AIDS fear that disclosure of their condition will affect employment, health insurance coverage, and even housing. Since healthcare providers do not share a client's diagnosis with a support group, option A is incorrect. Caring for a client with an infectious terminal illness that can be transmitted to other people is a concern for healthcare providers but it is not an ethical issue.

34. There are many ethical issues in the care of clients with HIV or HIV/AIDS. What is an ethical issue healthcare providers deal with when caring for clients with HIV/AIDS? a) Caring for a client who can kill other people b) Sharing the diagnosis with a support group c) Disclosure of the client's condition d) Caring for a client with an infectious terminal disease

c) 3 mL/min Pg. The intravenous infusion should be administered at a slow rate, not to exceed 3 mL/min.

35. When a nurse infuses gamma globulin intravenously, the rate should not exceed a) 10 mL/min b) 6 mL/min c) 3 mL/min d) 1.5 mL/min

c) Teach the client about medication side effects Pg. 1016 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.

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

c) There is complete lack of antibody production d) Disease onset occurs most often in the second decade of life e) There is a disappearance of germinal centers from lymphatic tissue Pg. 1006 Two types of inherited B-cell deficiencies exist. The first results from lack of differentiation of B-cell precursors into mature B cells. As a result, plasma cells are absent, and the germinal centers from all lymphatic tissues disappear, leading to a complete absence of antibody production against invading bacteria, viruses, and other pathogens. Although it usually presents within the first two decades of life, most clients are diagnosed as adults, because CVID often goes unrecognized. CVID is the most common primary immunodeficiency seen in adults, not childhood.

4. What are the characteristics of a B-cell deficiency, such as common variable immune deficiency (CVID)? Select all that apply. a) It is associated with the most common immunodeficiency seen in childhood b) There is an excess of plasma cells c) There is complete lack of antibody production d) Disease onset occurs most often in the second decade of life e) There is a disappearance of germinal centers from lymphatic tissue

d) "Be sure to take this drug about 1/2 hour before or 2 hours after you eat" Pg. 1018 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.

5. A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client? a) "You should take the drug with an antacid" b) "When you take this drug, eat a high-fat meal immediately afterwards" c) "It doesn't matter if you take this drug with or without food" d) "Be sure to take this drug about 1/2 hour before or 2 hours after you eat"

d) "The majority of primary immunodeficiencies are diagnosed in infancy" Pg. 1005 The majority of primary immunodeficiencies are diagnosed in infancy, with a male-to-female ratio of 5 to 1.

9. A nurse is teaching the parents of an infant about primary immunodeficiencies. Which statement verifies that the parents understand the teaching? a) "The primary immunodeficiency will disappear with age" b) "My baby cannot survive into childhood with a diagnosis of primary immunodeficiency" c) "Girls are diagnosed with primary immunodeficiencies more often than boys" d) "The majority of primary immunodeficiencies are diagnosed in infancy"