HIV & Immune Deficiency NCLEX
What is the NORMAL CD4+ cell count lab value?
500 to 1,500
A nurse assesses a neutrophil count of 900/mm3 in a patient with acute leukemia. What should the nurse anticipate initiating? a. A high-protein diet b. Increased doses of steroids c. Compromised host precautions d. Injections of blood-building medication
C ~ Patients with neutrophil counts of approximately 1000 cells/mm3 are placed on compromised host precautions.
What does enzyme reverse transcriptase transcribe? a. DNA to mimic CD4 cells b. T4-helper cells to RNA c. HIV RNA to HIV DNA d. T4 cells to HIV virions
C ~ Reverse transcriptase reverses the normal process and allows the RNA to be transcribed to the DNA rather than the DNA to be transcribed to the RNA.
What is dexamethasone?
A corticosteroid similar to a natural hormone produced by your adrenal glands. It often is used to replace this chemical when your body does not make enough of it. It relieves inflammation (swelling, heat, redness, and pain) and is used to treat certain forms of arthritis; skin, blood, kidney, eye, thyroid, and intestinal disorders (e.g., colitis); severe allergies; and asthma.
A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
A ~ A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.
What should a nurse include when developing a plan of care for a patient with human immunodeficiency virus (HIV)? a. Careful aseptic technique to prevent infection b. Instruction to limit fluids to prevent congestive heart failure c. Oral alcohol rinses to control mouth infections d. Selections of high-fat foods in the daily diet
A ~ A major complication of HIV is opportunistic infections.
The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client
A ~ According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.
The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse
A ~ Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.
A nurse is caring for a patient with thrombotic thrombocytopenic purpura who is having plasmapheresis every day. Which assessment alerts the nurse of a complication? a. Hypotension b. Seizure activity c. Diarrhea d. Intense headache
A ~ During the period of treatment by plasmapheresis, the patient can become hemodynamically unstable and have a reduced cardiac output with the attendant hypotension. This is a serious complication and can lead to renal failure.
What is true concerning passive-acquired immunity? a. Antibodies are acquired from outside the host and instilled in the host. b. Antibodies are manufactured in response to a disease in the host. c. Antibodies are innately acquired because of being born a human being. d. Antibodies are cell mediated inside the host.
A ~ Gamma globulin injections provide passive-acquired immunity. The antibodies that are injected have been produced by another host, collected, fused in the mixture, and injected into a separate host. This gives the host a passive-acquired immunity that lasts for only 2 to 3 months.
Which human immunity is an example of innate immunity? a. Hoof-and-mouth disease b. Measles c. Rabies d. Mange
A ~ Humans, by nature of their innate properties at birth, have an innate immunity to hoof-and-mouth disease. Cows also have an innate immunity to measles.
A patient diagnosed with leukemia has had a bone marrow transplant and has completed chemotherapy. What is the greatest risk for this patient while healthy bone marrow is growing back? a. Infection and bleeding b. Hypertension and headache c. Oliguria and urinary retention d. Dyspnea and wheezing
A ~ Patients are at greater risk for infection and bleeding while their healthy bone marrow is growing back.
A patient has undergone bone marrow transplant. Which injection should the nurse anticipate this patient will receive to help stabilize the immune response and prevent rejection? a. Dexamethasone (Decadron) b. Filgrastim (Neupogen) c. Zidovudine (Retrovir) d. Nevirapine (Viramune)
A ~ Steroids (e.g., dexamethasone [Decadron]) are drugs used in the treatment of patients with transplanted organs to prevent rejection.
Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications
A, B, D ~ A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.
A ~ The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the clients sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.
Which symptom should a nurse recognize as being pertinent to a possible diagnosis of systemic lupus erythematosus (SLE)? a. Butterfly rash of the face b. Protruding abdomen c. Thinning hair d. Bloody diarrhea
A ~ The classic butterfly rash of the face is one of the most recognizable signs. Because the symptoms come and go, SLE is extremely hard to diagnose quickly.
A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.
A ~ The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.
A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.
A ~ The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.
A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.
A ~ The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.
What is the primary function in the immune process of the spleen? a. Filter microorganisms from the blood. b. Store lymphocytes used to fight infections. c. Produce additional RBCs (red blood cells). d. Stimulate WBC production.
A ~ The spleen filters microorganisms from the blood.
The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.
A ~ This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.
A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.
A ~ This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.
An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.
A ~ Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.
A nurse explains that in autoimmune diseases, the body identifies its own proteins as foreign matter and sets out to destroy itself. Which are examples of autoimmune diseases? (Select all that apply.) a. SLE b. Type 1 diabetes mellitus (DM) c. Rheumatoid arthritis (RA) d. Osteoarthritis e. Pancreatitis
A, B, C ~ The autoimmune diseases are SLE, type 1 DM, and RA.
A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.
A, B, C, D ~ In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.
What are the four distinct stages of the inflammatory process? a. Dolor b. Rubor c. Tumor d. Calor e. Rumor
A, B, C, D ~ The four processes are rubor (red), tumor (swelling), calor (heat), and dolor (pain).
A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes
A, B, C, D ~ Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.
A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the clients mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the clients abdomen.
A, C, D ~ Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.
A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L
A, D, E ~ The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal.
Define ANERGY
Absence of the normal immune response to a particular antigen or allergen
Which laboratory result for a patient with acute leukemia should alert the nurse to the fact that the drug protocols are not effective? a. Decreased prothrombin time b. Platelet count lower than 50,000/mm3 c. Negative Western blot result d. Neutrophils 50% to 62%
B ~ A low platelet count predisposes a patient to bleeding. A count less than 50,000/mm3 is cause for concern.
What is responsible for initiating the inflammatory response in addition to immunoglobulin E (IgE)? a. Eosinophils b. Lymphocytes c. Basophils d. Neutrophils
C ~ Basophils initiate a massive inflammatory response with histamine that quickly brings other white blood cells (WBCs) to the site of an infection.
A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.
B ~ Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.
A nurse is preparing a patient for a liver and spleen scan. Which intervention is most important to implement before the procedure? a. Prepare the biopsy site with a clean field. b. Check for any allergies to contrast media. c. Explain the procedure to the patients family. d. Have the patient eat a complete regular diet.
B ~ Allergies should always be checked before any diagnostic test.
A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination
B ~ Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.
A very anxious young man comes to the clinic believing that he may have HIV infection because of his persistent influenza-like symptoms and his risky sexual behavior. What should the nurse anticipate that a positive blood analysis would show? a. High levels of CD8 cells b. High levels of HIV-infected cells c. Low levels of T cells d. Low levels of antibodies
B ~ In the initial phase of HIV infection, high levels of HIV-infected cells, high levels of T cells, and high levels of antibodies are present as the body attempts to rid the body of the virus through the immune response.
The nursing staff of an oncology unit cautions visitors to be free of infections before visiting patients. What can chemotherapy and decreased bone marrow production cause in these patients? a. Hemorrhage b. Neutropenia c. Edema d. Hypovolemia
B ~ Neutropenia occurs when the total number of neutrophils is abnormally low, placing the patient at increased risk for infection.
Which population, according to statistics from the Centers for Disease Control and Prevention (CDC), has the greatest incidence of human immunodeficiency viral (HIV) infection in the United States? a. Asian Americans b. African Americans c. Latinos d. Whites
B ~ Of those with HIV infection in the United States, African Americans make up 49%, whites 27%, and Latinos 12%. Asian Americans were not reported.
A patient taking dexamethasone (Decadron) reports insomnia. What is the best information to provide this patient regarding administration of this medication? a. Take with milk. b. Take at breakfast. c. Dissolve in fruit juice. d. Take at bedtime.
B ~ Patients taking steroids should take them early in the day to avoid sleep disturbances.
A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management? a. Infusions will be scheduled every 3 to 4 weeks. b. Treatment is aimed at treating specific infections. c. Unfortunately, there is no effective treatment. d. You will need many immunoglobulin A infusions.
B ~ Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.
A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the clients fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities
B, C, D, E ~ The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.
A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.
B, C, E ~ The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.
A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug. c. This drug helps treat the pain from nerve irritation. d. You are at risk for seizures due to fungal infections.
C ~ Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.
Where are histamine-releasing mast cells located? a. Circulating in the blood b. Circulating in the lymph c. Attached to organ tissue d. Embedded in the bone marrow
C ~ Mast cells are located in organ tissue when they release their histamine. The organ to which they are attached is the host of the inflammatory response. If the organ is the lung, the response may be asthma; if the organ is the colon, the response may be diarrhea.
What is most appropriate for a nurse to include when preparing discharge plans for a patient with SLE? a. Need to consume 2 L of fluid daily b. Close monitoring of daily blood glucose level c. Use of daily sunscreens with a sun protection factor (SPF) higher than 15 d. Careful concern for certain food allergies
C ~ Patients with SLE are photosensitive to sunlight.
Which nursing action should be implemented when performing skin testing? a. Select an 18-gauge needle. b. Inject 1 mL intradermally. c. Check the site in 2 to 3 days for swelling. d. Wrap the site with a pressure dressing.
C ~ A cell-mediated response will show swelling in 2 to 3 days, indicating antibodies working at the site of the exposure to an antigen.
When is a patient with HIV considered to have progressed to AIDS? a. Two or more opportunistic infections are diagnosed. b. Kaposi sarcoma appears. c. CD4 cell level drops to 200. d. Patient tested positive for enzyme-linked immunosorbent assay (ELISA).
C ~ A person with an HIV infection is not diagnosed with AIDS until the CD4 count falls to 200. Other AIDS markers exist as well.
Which observation by a nurse indicates a patients acceptance of the diagnosis of acute leukemia? a. Plans a 14-day cruise in 2 weeks b. States that he will be fine in a few months c. Asks for educational material about acute leukemia d. Rests after a chemotherapy session
C ~ Asking for educational material indicates beginning acceptance.
A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.
C ~ Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alternative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.
The nursing staff decides on a nursing diagnosis of Imbalanced nutrition: less than body requirements for a patient with leukemia. Which goal is most realistic for this patient? a. To gain 5 lb, eat foods high in calories at each meal. b. To avoid nausea, eat slowly, and eat small meals. c. To consume all food at every meal, offer three large meals. d. To maintain a stable weight, eat small meals, and avoid vomiting.
D ~ A goal for Imbalanced nutrition: less than body requirements would be maintaining a stable weight.
A nurse is alerted by the laboratory regarding a patients complete blood count that shows a large shift to the left. What should the nurse assess this to mean about cell level count? a. Neutrophils have dropped by 10%. b. Basophils have increased by 25%. c. Neutrophils have increased by 25%. d. Neutrophils have increased by 60%.
D ~ A shift to the left indicates a sharp rise in the neutrophils to approximately 60%. The outpouring of these cells from the marrow indicates a serious and perhaps overpowering infection. Many of the cells are young and will not be able to keep up their work of immunity for as long as more mature cells would maintain immunity.
A skin test shows redness and swelling a few days after injection. What type of hypersensitivity reaction should the nurse document? a. I b. II c. III d. IV
D ~ A type IV reaction is set in motion when immune cells migrate to the site of an antigen exposure and set up a local inflammatory response.
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly
D ~ All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.
What type of bone marrow transplant uses the patients own bone marrow? a. Allergenic b. Allogeneic c. Peripheral blood stem cell d. Autologous
D ~ An autologous bone marrow transplant uses the patients own bone marrow.
A nurse is assessing a patient with AIDS for risk factors. What is recognized as the most risky behavior in the patient history? a. Oral sex without contact with the glans penis b. Oral sex with a condom c. Use of sex toys d. Anal sex with a condom
D ~ Anal sex, even with a condom, is a higher risk behavior than the other three options.
An 11-year-old girl is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which parental statement helps the nurse evaluate that teaching is successful? a. Our daughter can still be involved in gymnastics. b. When our daughters hemoglobin falls below 3.5, shell need blood. c. Our daughter will need genetic counseling before she marries. d. Our daughter should avoid drugs containing sulfonamides.
D ~ Drugs known to induce ITP include sulfonamides.
After a bone marrow transplant, a patient is placed on a protocol of chemotherapy and radiation and the nursing diagnosis of risk for injury is added. Which nursing assessment should cause the nurse concern? a. Increased urine output b. Decreasing bilirubin levels c. Increasing blood pressure d. Increasing abdominal girth
D ~ High doses of chemotherapy and radiation can damage the liver, which would lead to increasing abdominal girth with ascites and increasing bilirubin levels.
A nurse is caring for a patient in the last stages of leukemia and is aware that the patient is at risk from the bacteria of his own body. Which is an example of internal bacteria? a. Beta-hemolytic streptococci b. Streptococcus pneumoniae c. Streptococcus viridans d. Pseudomonas aeruginosa
D ~ Internal bacteria such as P. aeruginosa and Escherichia coli are capable of attacking the compromised immune system from inside the body.
What is the most common form of transmission of the HIV virus? a. Injection drug use b. Heterosexual contact c. Exposure to contaminated blood products d. Male to male
D ~ Male-to-male transmission is still the most common mode.
A 24-year-old woman is admitted to the hospital for a complete medical examination. Her current complaints are indicative of SLE. Which symptom would indicate this diagnosis? a. Recent weight gain of 10 lb b. Difficulty breathing in the morning c. Frequent episodes of diarrhea d. Musculoskeletal pain in the hands
D ~ Musculoskeletal symptoms are experienced by 95% of patients with SLE at some time during the course of their disease.
A hospitalized patient has been prescribed dexamethasone (Decadron) for an allergic reaction. Which teaching instruction should the patient be given with discharge relative to this drug? a. Report blurry vision. b. Take the medication on an empty stomach. c. Do not operate heavy machinery. d. Take this medication with meals.
D ~ Steroid therapy can cause gastrointestinal discomfort when taken on an empty stomach.
A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month
D ~ The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.
A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest.
D ~ This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the clients activity.
An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.
D ~ Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.
Cells in the bone marrow that are capable of developing into RBCs, WBCs, or platelets are the _____ cells.
stem ~ Adult stem (progenitor) cells can evolve into WBCs, RBCs, or platelets. Stem cells from an embryo can mature into any specialized cell. Adult stem cells are limited to cells of their origin.
A nurse explains that early in life, lymphocytes migrate from the marrow of the bones to the _____, in which they mature into T cells.
thymus ~ The lymphocytes migrate and mature to T cells in the thymus.
