med surg ch 19

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.)

Assisting the client to get out of bed to prevent falls Obtaining a bedside commode if the client is weak Providing gentle perianal cleansing after stools Reporting any perianal abnormalities

The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest?

Anal intercourse

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.)

Aspartate transaminase, alanine transaminase: elevated Platelet count: 80,000/mm3 Serum sodium: 120 mEq/L

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?

Assess the client for adherence to the drug regimen.

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?

Assess the client for support systems

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.)

Assess the client's mouth and throat. Ensure that the consent form is on the chart. Maintain NPO status as prescribed.

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?

Assess the client's sexual activity and patterns.

A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?

Assessing mucous membranes

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.)

Assist the client with oral care every 2 hours. Offer the client frequent sips of cool drinks. Remind the client to use only a soft toothbrush.

Which findings are AIDS-defining characteristics? (Select all that apply.)

CD4+ cell count less than 200/mm3 or less than 14% Infection with Pneumocystis jiroveci Presence of HIV wasting syndrome

A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.)

CD4+ cells begin to create new HIV virus particles. Antibodies produced are incomplete and do not function well. Macrophages stop functioning properly. Opportunistic infections and cancer are leading causes of death.

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.)

Clean drinking water Cultural beliefs about illness Lack of antiviral medication Social stigma

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first?

Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4° F (39.1° C)

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?

Confront the staff members about unethical behavior.

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?

Consistent use of Standard Precautions

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?

Consult with the pharmacy about drug interactions

A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best?

Contact the social worker to assist the client with advance directives.

The nurse is caring for a client diagnosed with human immune deficiency virus. The client's CD4+ cell count is 399/mm3. What action by the nurse is best?

Counsel the client on safer sex practices/abstinence.

A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?

Disposing of soiled dressings properly

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?

Has a weight gain of 2 pounds/1 month

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?

Pace activities, allowing for adequate rest.

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?

Place the client under Airborne Precautions.

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?

This drug helps treat the pain from nerve irritation.

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?

Treatment is aimed at treating specific infections

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?

Truvada does not reduce the need for safe sex practices

An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?

Use Standard Precautions consistently.