Chapter 14: HIV
Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with patient vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure
A. Needle stick with a needle and shrine used to draw blood Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.
Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation
A. Patient age The current CDC policy is to offer routine testing for HIV to all individuals age 13 to 64. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.
A patient who has vague symptoms of fatigue and headaches is found to have a positive enzyme immunoassay (EIA) for human immunodeficiency virus (HIV) antibodies. In discussing the test results with the patient, the nurse informs the patient that a. the EIA test will need to be repeated to verify the results. b. a viral culture will be done to determine the progress of the disease. c. it will probably be 10 or more years before the patient develops acquired immunodeficiency syndrome (AIDS). d. the Western blot test will be done to determine whether AIDS has developed.
A. the EIA test will need to be repeated to verify the results After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not part of HIV testing. Because the nurse does not know how recently the patient was infected, it is not appropriate to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.
To evaluate the effectiveness of ART, the nurse will schedule the patient for a. viral load testing. b. enzyme immunoassay. c. rapid HIV antibody testing. d. immunofluorescence assay.
A. viral load testing The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.
The nurse uses a visual aid to demonstrate how nonnucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) work to combat HIV by: a. interfering with replication of the virus. b. stimulating production of CD4 helper cells. c. making a hostile environment for the virus. d. dissolving the virus.
ANS: A Both types of drugs interfere with the replication of the virus.
An HIV-positive patient is diagnosed with Kaposi sarcoma (KS). The patient asks why highly active antiretroviral therapy (HAART) is being prescribed for him. Which response by the nurse is most accurate? a. HAART will help stop the progression of your skin lesions. b. HAART will prevent you from getting AIDS. c. HAART will treat any current opportunistic infections you have. d. HAART will eliminate your HIV.
ANS: A KS is a common malignancy in HIV-positive patients and appears as discolored areas on the skin, but can also form inside of the mouth, lungs, and intestines. HAART can stop the progression of skin lesions in some patients and may even eliminate the lesions. HAART can slow the progression of HIV, but cannot eliminate the HIV infection or the possibility of progression into AIDS. Antibiotics are used to treat infections.
The nurse is aware that Pneumocystis jiroveci (P. carinii, or PCP) becomes a real threat when the immunosuppressed patients CD4 count drops to _____ cells/mm3. a. 200 b. 400 c. 600 d. 1000
ANS: A Pneumocystis jiroveci is considered an opportunistic infection in the patient who is HIV positive. When the CD4 count drops to 200 cell/mm3, the HIV-positive patient is vulnerable to opportunistic infections.
An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching? a. Many medications have interactions with antiretroviral drugs. b. Less frequent CD4+ level monitoring is needed in older adults. c. Hospice care is available for patients with terminal HIV infection. d. Progression of HIV infection occurs more rapidly in older patients.
ANS: A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient with asymptomatic HIV infection is not a candidate for hospice. Progression of HIV is not affected by age, although it may be affected by chronic disease.
In the event of an accidental exposure to HIV through a needle stick, the nurse should be given a protocol of 1 to 3 drugs for a period of _____ weeks. a. 4 b. 8 c. 12 d. 16
ANS: A The protocol should be taken for a period of 4 to 6 weeks.
The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin
ANS: A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.
The nurse is providing patient education to the patient newly diagnosed with HIV. When explaining sentinel infections to the patient, the nurse should include which infection? (Select all that apply.) a. Oral thrush b. Recurrent vaginal yeast infections c. Skin infections d. Tuberculosis e. Encephalopathy
ANS: A, B, C Sentinel infections are opportunistic infections that may indicate underlying immunosuppression. Tuberculosis and encephalopathy are considered category C AIDS defining infections.
The nurse makes a list of conditions that can cause acquired immune deficiency, which includes: (Select all that apply.) a. chemotherapy. b. viral infections. c. smoking. d. malnutrition. e. bacterial infections.
ANS: A, B, C, D Bacterial infections do not cause immune deficiency.
The school nurse instructing a group of high school sophomores in safe sex practices should include which practice(s) in her teaching? (Select all that apply.) a. Use a condom. b. Use a spermicide. c. Practice abstinence. d. Get vaccinated against HIV. e. Avoid unprotected orogenital sex.
ANS: A, C, E HIV can be transmitted by sexual practices of not using a condom and through orogenital sex. Abstinence is the only way to ensure that HIV is not transmitted through sexual intercourse. Spermicides do not prevent HIV transmission, and there is no vaccination against HIV.
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient about how to use tissues to dispose of respiratory secretions. b. Stock the patient's room with all the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.
ANS: B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time? a. Oral acyclovir (Zovirax) b. Oral saquinavir (Invirase) c. Nystatin (Mycostatin) tablet d. Aerosolized pentamidine (NebuPent)
ANS: B It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Avoid sexual intercourse when using injectable drugs." b. "It is important to participate in a needle-exchange program." c. "You should ask those who share equipment to be tested for HIV." d. "I recommend cleaning drug injection equipment before each use.
ANS: B Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time? a. Teach about the effects of antiretroviral agents. b. Encourage adequate nutrition, exercise, and sleep. c. Discuss likelihood of increased opportunistic infections. d. Monitor for symptoms of acquired immunodeficiency syndrome (AIDS).
ANS: B The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection, when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.
The nurse is caring for an immune compromised patient who complains of itching and tingling from below the shoulder on the back around to the chest area, as well as burning and shooting pain, headache, and low-grade fever. The nurse is aware that this patient is most likely experiencing: a. hepatitis C. b. shingles. c. a bacterial infection. d. cryptococcosis.
ANS: B The immune compromised patient may experience opportunistic infections. Hepatitis C, bacterial infections, and cryptococcosis are all opportunistic infections, but the symptoms this patient is experiencing are consistent with shingles.
An HIV patient has lost more than 10% of her weight along with having diarrhea for the last 30 days. The nurse knows that these are indications of: a. AIDS. b. wasting syndrome. c. an opportunistic infection. d. anorexia.
ANS: B Wasting syndrome is a physiologic problem associated with HIV infection. It is defined as losing more than 10% of weight along with at least 30 days of either diarrhea or weakness accompanied by fever. The patient loses not only body fat but also muscle mass. It is often an indication of progression of the HIV infection.
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.
ANS: C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.
The hospitalized patient with an HIV infection who is being treated for Mycobacterium tuberculosis (MTb) demonstrates understanding of care when stating: a. I am fortunate that I will not need to be in transmission-based precautions for this infection. b. My family will have to get special testing because the normal PPD test is not used to detect exposure to this infection. c. It is important for me to take my rifampin medication for the next year. d. This infection will only cause problems with my lungs.
ANS: C Rifampin therapy usually lasts for a minimum of 6 to 12 months. Transmission-based precautions are necessary for MTb. PPD testing can be used for screening of MTb. MTb can affect other areas, such as the central nervous system, GI tract, and spleen.
When oral thrush, recurrent vaginal yeast infections, or skin disorders appear in the HIV-positive patient, the nurse assesses this as: a. AIDS. b. invasion of primary pathogens. c. a sign of a failing immune system. d. retrovirus infection.
ANS: C Sentinel infections are opportunistic infections that may indicate underlying immunosuppression in the HIV-infected patient. It is not a definitive sign that AIDS has occurred, nor are these classified as primary pathogens. HIV is a retrovirus that incorporates itself into the genetic material of the host cells it infects, thus altering the DNA.
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions
ANS: C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.
The nurse is working in a trauma unit and is accidentally stuck with an IV needle following venipuncture of the patient. What is the nurses first action? a. Immediately begin taking the two- or three-drug regimen. b. Report the stick to the charge nurse immediately so follow-up can be initiated. c. Wash the punctured area with soap and water. d. Complete an incident report so immediate testing of the patient and nurse can begin.
ANS: C The area should first be cleansed in an attempt to flush any pathogenic organisms from the site, followed by reporting the incident to the charge nurse and completing an incident report. Appropriate treatment regimen will then be started.
Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose latest CD4+ count is 250/µL b. Patient whose rapid HIV-antibody test is positive c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs
ANS: C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.
The nurse describes the initial diagnostic test for HIV as the enzyme-linked immunosorbent assay (ELISA), which is performed to detect: a. human immunodeficiency virus. b. depleted phagocytes. c. numbers of T helper cells. d. HIV antibodies.
ANS: D The ELISA looks for HIV antibodies. There is no test that can detect the HIV virus itself.
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the drugs should be taken.
ANS: D The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.
ANS: D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection.
A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Since she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral drug therapy (ART).
B. Most infants born to HIV-positive mothers are not infected with the virus Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Advise the patient that this is probably the flu. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.
C. Explain to the patient that this is an expected finding. Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Applying ice to the neck may provide comfort, but the initial action is to reassure the patient this is an expected finding. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu.
A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. teach the patient about the medications available for treatment. b. inform the patient how to protect sexual and needle-sharing partners. c. remind the patient about the need to return for retesting to verify the results. d. ask the patient to notify individuals who have had risky contact with the patient.
C. remind the patient about the need to return for retesting to verify the results After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is best? a. "Thinking about dying will not improve the course of AIDS." b. "It is important to focus on the good things about your life now." c. "Do you think that taking an antidepressant might be helpful to you?" d. "Can you tell me more about the kind of thoughts that you are having?
D. "Can you tell me more about the kind of thoughts you are having?" More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patient's feelings.
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. A patient who is currently HIV negative but has unprotected sex with multiple partners b. A patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µl c. An HIV-positive patient with a CD4+ count of 120/µl who drinks a fifth of whiskey daily d. A patient who tested positive for HIV 2 years ago and has cytomegalovirus (CMV) retinitis
D. A patient who tested positive for HIV 2 years ago and has cytomegalovirus (CMV) retinitis CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. HIV genotype and phenotype b. Patient's social support system c. Potential medication side effects d. Patient's ability to comply with ART schedule
D. Patient ability to comply with ART schedule Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient meets the criteria for a diagnosis of an acute HIV infection." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient has developed acquired immunodeficiency syndrome (AIDS)." d. "The patient will develop symptomatic chronic HIV infection in less than a year."
c. "The patient has developed acquired immunodeficiency syndrome (AIDS)." Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other responses indicate an earlier stage of HIV infection than is indicated by the PCP infection.
A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Driving is allowed when starting this medication. b. Report any bizarre dreams to the health care provider. c. Continue to use contraception while on this medication. d. Take this medication in the morning on an empty stomach.
c. Continue to use contraception while on this medication. Efavirenz can cause fetal anomalies and should not be used in patients who may be pregnant. The drug should not be used during pregnancy because large doses could cause fetal anomalies. Once-a-day doses should be taken at bedtime (at least initially) to help patients cope with the side effects that include dizziness and confusion. Patients should be cautioned about driving when starting this drug. Patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams.