MS2 - Ch. 36: Immune Deficiency Disorders
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?
"Although AIDS is an immune deficiency, your child's condition is different from AIDS." 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.
A client is prescribed didanosine as part of a highly active antiretroviral therapy (HAART). Which instruction would the nurse emphasize with this client?
"Be sure to take this drug about 1/2 hour before or 2 hours after you eat." 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.
A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?
"I can eat whatever I want as long as it's low in fat." The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client.
The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed?
"I can take my child to the beach, as long as we play in the sand rather than swim in the water." Parents should verbalize ways to plan for regular exercise and activity that does not pose a risk of infections. Immunocompromised clients should avoid touching sand or soil because of the high level of bacteria and increased risk of diseases such as toxoplasmosis.
A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?
"I understand your concern. The blood is screened very carefully for different viruses as well as HIV." Blood and blood products can transmit HIV to recipients. However, the risk associated with transfusions has been virtually eliminated as a result of voluntary self-deferral, completion of a detailed health history, extensive testing, heat treatment of clotting factor concentrates, and more effective virus inactivation methods. Donated blood is tested for antibodies to HIV-1, human immunodeficiency virus type 2 (HIV-2), and p24 antigen; in addition, since 1999, nucleic acid amplification testing (NAT) has been performed.
The nurse is instructing a male client about safer sexual behaviors. Which client statement indicates a need for additional instruction?
"I will apply baby oil to lubricate the condom." The client should use only water-soluble lubricant, such as K-Y jelly or glycerin. Baby oil can cause the condom to break. The client should use a new condom for each sexual activity and hold onto the condom so that it does not come off when pulling out. Manual-anal intercourse should be avoided.
The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed?
"I will be sure to eat lots of fresh fruits and vegetables every day." The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.
The nurse is obtaining an assessment and health history from the parents of a 6-month-old infant with an elevated temperature. Which statement by the parents alerts the nurse to a possible immunodeficiency disorder?
"This is the third infection with a high fever the baby has had in the past month." Infants with X-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins, which occurs at about 5 to 6 months of age. Symptoms of recurrent pyogenic infections usually occur by that time.
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.
"Your immune system was most likely affected by an underlying disease process." 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.
As part of HAART therapy, a client is prescribed a non-nucleoside reverse transcriptase inhibitor (NNRTI). What would be an example of a drug from this class? Select all that apply.
-Efavirenz -Delavirdine Examples of NNRTIs are delavirdine and efavirenz. Abacavir and stavudine are nucleoside reverse transcriptase inhibitors (NRTIs). Amprenavir is a protease inhibitor.
A secondary immunodeficiency is characterized by the following. Choose all that apply.
-It may be caused by certain viruses. -It usually occurs as a result of underlying disease processes. -It frequently is caused by certain autoimmune disorders. Secondary immunodeficiencies are more common than primary immunodeficiencies and frequently result from underlying disease processes or their treatment. Common causes of secondary immunodeficiencies include chronic stress, burns, uremia, diabetes mellitus, certain autoimmune disorders, certain viruses, exposure to immunotoxin medications and chemicals, and self-administration of recreational drugs and alcohol.
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.
-Tightness in the chest -Flank pain -Shaking chills 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.
The nurse is administering an infusion of gamma-globulin to a patient in the hospital. When should the nurse discontinue the infusion? (Select all that apply.)
-When the patient complains of nausea -When the patient begins to have shaking chills -When the patient complains of flank pain -When the patient complains of tightness in the chest Stop the infusions at the first sign of reaction, and initiate the institutional protocol to be followed in this emergent situation. Reactions include complaints of flank and back pain, shaking chills, flushing, dyspnea, and tightness in the chest; headache, fever, muscle cramps, nausea/vomiting, and local reaction at the infusion site.
The nurse is preparing to infuse gamma-globulin intravenously (IV). When administering this drug, the nurse knows the speed of the infusion should not exceed what rate?
3 mL/min The nurse should administer the IV infusion at a slow rate, not to exceed 3 mL/min, usually at 100-200 mL/h.
A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time?
6 weeks Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels.
A nurse is preparing an in-service presentation about human immunodeficiency virus (HIV) for a group of new graduate nurses, including the steps in the process of HIV entering the host cell. What would the nurse describe as the first step?
Attachment Once HIV enters the host cell, attachment occurs in which the glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors. This is followed by uncoating, in which HIV's viral core is emptied into the CD4+ T cell. Cleavage and budding occur as the last steps.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation Treatment options for SCID include stem cell and bone marrow transplantation.
A client with acquired immune deficiency syndrome (AIDS) informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the client has developed?
Candidiasis Candidiasis, a fungal infection, occurs in almost all clients with AIDS and immune depression (Durham & Lashley, 2010). Oral candidiasis is characterized by creamy-white patches in the oral cavity and, if left untreated, can progress to involve the esophagus and stomach. Associated signs and symptoms include difficult and painful swallowing and retrosternal pain.
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:
Chronic diarrhea. 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.
Other than abstinence, what is the only proven method of decreasing the risk of sexual transmission of HIV infection?
Consistent and correct use of condoms Other than abstinence, consistent and correct use of condoms is the only method proven to decrease the risk for sexual transmission of HIV infection. Vaginal lubricants, birth control pills, and spermicides are not proven means of decreasing the risk for sexual transmission of HIV infection.
Which microorganism is known to cause retinitis in people with HIV/AIDS?
Cytomegalovirus Cytomegalovirus is a species-specific herpes virus. C. neoformans is a fungus that causes an opportunistic infection in clients with HIV/AIDS. M. avium is an acid-fast bacillus that commonly causes a respiratory illness. P. carinii is an organism that is thought to be protozoan, but believed to be a fungus based on its structure.
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?
Disclosure of the client's condition 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.
A client is suspected of having an immune system disorder. The health care provider wants to perform a diagnostic test to confirm the diagnosis. What test should the nurse prepare the client for?
Enzyme-linked immunosorbent assay T-cell and B-cell assays (or counts) and the enzyme-linked immunosorbent assay may be performed. A C-cell assay and plasmapheresis are distractors for this question. A complete chemistry panel is not a diagnostic test for an immune system disorder.
Which blood test confirms the presence of antibodies to HIV?
Enzyme-linked immunosorbent assay (ELISA) ELISA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. The p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.
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?
Enzyme-linked immunosorbent assay (ELISA) 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.
A woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV?
Gynecologic problems In women with HIV, gynecologic problems, such as abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may be the focus of a majority of complaints. Acute retroviral syndrome (viremia) may be the chief complaint in one third to more than one half of those infected, not necessarily women. Its manifestations include rashes, muscle and joint pain, and weight loss.
When learning about HIV/AIDS, the student should be able to differentiate the two subtypes of virus by which characteristic?
HIV-1 is more prevalent than HIV-2 subtypes 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.
Which condition is an early manifestation of HIV encephalopathy?
Headache Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.
During a third-trimester transabdominal ultrasound, cardiac anomaly and facial abnormalities are noted in the fetus. Further testing reveals that the thymus gland has failed to develop normally, and the fetus is diagnosed with thymic hypoplasia. Based on this diagnosis, the nurse anticipates careful monitoring for which common manifestation during the first 24 hours of life?
Hypocalcemia The most frequent presenting sign in clients with thymic hypoplasia (DiGeorge syndrome) is hypocalcemia that is resistant to standard therapy. It usually occurs within the first 24 hours of life.
A client who is HIV positive is experiencing severe diarrhea. Which laboratory test result would the nurse expect to find?
Hypokalemia Electrolyte imbalances such as decreased sodium, potassium, calcium, magnesium, and chloride typically result from profuse diarrhea. A urine specific gravity of 1.010 would indicate dilute urine. The client with severe diarrhea most likely would be dehydrated, leading to a high urine specific gravity. Proteinuria may suggest renal dysfunction and would not be associated with severe diarrhea unless the client was developing renal failure.
The nurse teaches the client that reducing the viral load will have what effect?
Longer survival The lower the client's viral load, the longer the survival time and the longer the time to AIDS diagnosis.
A client seen in the outpatient clinic has common variable immunodeficiency. It is important for the nurse to teach the client about the need for more frequent screening for which complication?
Malignancy Advances in medical treatment have meant that clients with primary immunodeficiencies live longer, thus increasing their overall risk of developing cancer. Non-Hodgkin lymphomas account for most cancers. The primary immunodeficiencies known to be associated with increased incidence of malignancy are common variable immunodeficiency, immunoglobulin A deficiency, and DNA repair disorders.
Which characteristic has NOT been implicated as a factor for noncompliance with antiretroviral treatment?
Past substance abuse Factors associated with nonadherence include active substance abuse, depression, and lack of social support, as well as neurocognitive impairment, low health literacy, stressful life events, high levels of alcohol consumption, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment.
A nurse knows that more than 50% of clients with CVID develop the following disorder.
Pernicious anemia More than 50% of clients with CVID develop pernicious anemia. Although chronic diarrhea may occur in clients with CVID, it does not happen in 50% of them. Hypocalcemia and neutropenia are not concerns for clients with CVID.
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?
Pernicious anemia More than 50% of clients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy, which is detected by biopsy of the stomach, are common findings. Gastrointestinal malabsorption may occur.
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?
Pneumocystis jiroveci 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.
A patient had unprotected sex with an HIV-infected person and arrives in the clinic requesting HIV testing. Results determine a negative HIV antibody test and an increased viral load. What stage does the nurse determine the patient is in?
Primary infection The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection, or stage 1. Initially, there is a period during which those who are HIV positive test negative on the HIV antibody blood test, although they are infected and highly infectious, because their viral loads are very high.
Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?
Respiratory or urinary system infections Secondary immunodeficiencies occur as a result of underlying disease processes or the treatment of these disorders, including administration of immunosuppressive agents. Abnormalities of the immune system affect both natural and acquired immunity. Because immunodeficiencies result in a compromised immune system and pose a high risk for infection, careful assessment of the client's immune status is essential. The nurse assesses and monitors the client for signs and symptoms of infection.
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material?
Ribonucleic acid (RNA) HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Risk for injury In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.
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?
Side effects of drug therapy 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.
A parent brings a young child to the clinic for an evaluation of an infection. The parent states, "my child has been taking antibiotics now for more than 2 months and still doesn't seem any better." During the history and physical examination, what would alert the nurse to suspect a primary immunodeficiency?
Ten ear infections in the past year The parent has already reported one of the warning signs associated with primary immunodeficiencies--the use of antibiotics for 2 or more months with little effect. Another warning sign is eight or more new ear infections within 1 year. Therefore, the report of 10 ear infections in the past year would increase the nurse's suspicion. Recurrent, deep skin, or organ abscesses, failure of an infant to gain weight or grow normally, and persistent thrush (yeast infection) in the mouth or elsewhere on the skin after age 1 year would be additional warning signs. A superficial wound on the leg, age-appropriate weight, and a history of a fungal diaper rash would not be considered warning signs.
Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives?
The female condom The female condom, the first barrier method controlled by women, is the only proven, effective method to prevent the transmission of HIV and sexually transmitted infections (STI).
The lower the client's viral load,
The longer the survival time The lower the client's viral load, the longer the time to AIDS diagnosis and the longer the survival time. The key goal of antiretroviral therapy is to achieve and maintain durable viral suppression.
Which is a major manifestation of Wiskott-Aldrich syndrome?
Thrombocytopenia Major symptoms of Wiskott-Aldrich syndrome include thrombocytopenia, infections, and malignancies. Ataxia occurs with ataxia-telangiectasia. Episodes of edema in various body parts occur with angioneurotic edema. Bacterial infection occurs with hyperimmunoglobulinemia E syndrome.
A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately?
Tickle in the throat Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction.
When the nurse administers intravenous gamma-globulin infusion, she recognizes that which symptom, if reported by the client, may indicate an adverse effect of the infusion?
Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion. Nasal stuffiness and increased thirst are not recognized as adverse effects of gamma-globulin infusion. Burning urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.
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?
Urine 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.
Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?
Vascular lesions Ataxia-telangiectasis is characterized by loss of muscle coordination and vascular lesions. Thrombocytopenia and eczema are associated with Wiskott-Aldrich syndrome. Thrush is a manifestation associated with severe combined immunodeficiency (SCID).
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:
Western blot test for confirmation of diagnosis. The enzyme-linked immunosorbent assay (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. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.
A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid:
alcohol 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.
Kaposi sarcoma (KS) is diagnosed through
biopsy KS is diagnosed through biopsy of the suspected lesions. Visual assessment will not confirm a diagnosis. A computed tomography scan will not assist in determining skin cell changes. Skin scraping is a procedure to collect cells, not to evaluate cells.
A client with AIDS has been tested for cytomegalovirus (CMV) with positive titers. What severe complication should the nurse be alert for with cytomegalovirus?
blindness CMV can infect the choroid and retinal layers of the eye, leading to blindness. It does not lead to hearing impairment. Fatigue and diarrhea may occur but are not as critical as blindness.
A nurse is assessing a client with a primary immunodeficiency. Afterward the nurse documents that the client displayed ataxia. The nurse makes this documentation because the client has
uncoordinated muscle movements. Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination).
