NUR 125 PrepU Chapter 32: Management of Patients with Immune Deficiency Disorders
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
The majority of patient with primary immunodeficiency are in which age group?
Younger than 20
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."
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 nurse identifies a nursing diagnosis of ineffective airway clearance related to pneumocystis pneumonia and increased bronchial secretions for a client with AIDS. Which of the following would be appropriate for the nurse to include in the client's plan of care?
Assist with chest physiotherapy every 2 to 4 hours.
Which is usually the most important consideration in the decision to initiate antiretroviral therapy?
CD4+ counts
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
More than 50% of individuals with this disease develop pernicious anemia:
Common variable immunodeficiency (CVID)
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
A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority?
Disturbed body image related to loss of fat in the face and arms
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)
Which blood test confirms the presence of antibodies to HIV?
Enzyme-linked immunosorbent assay (ELISA)
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.
Flank pain Shaking chills Tightness in the chest
A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen?
IV gamma globulin administration
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?
Immunosuppressive agents
What does the nurse understand will result if the patient has a deficiency in the normal level of complement?
Increased susceptibility to infection
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."
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."
A nurse is teaching the parents of an infant about primary immunodeficiencies. Which statement verifies that the parents understand the teaching?
"The majority of primary immunodeficiencies are diagnosed in infancy."
A client with AIDS has become forgetful with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?
AIDS dementia complex (ADC)
When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following?
Antibodies to HIV are not present in his blood.
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation
A home care nurse is visiting a client with acquired immune deficiency syndrome (AIDS) at home. During the visit, the nurse observes the caregiver providing care. What action by the caregiver would alert the nurse to the need for additional teaching?
Caregiver cleans the client's anal area without wearing gloves
A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." Which nursing action is the priority for this client?
Offer information on human immunodeficiency virus (HIV) testing.
A client is diagnosed with severe combined immunodeficiency (SCID). What would the nurse expect to integrate into the client's plan of care?
Preparation for bone marrow transplantation
When developing the plan of care for a client with a primary immunodeficiency, which nursing diagnosis would be the priority?
Risk for infection related to altered immune cell function
The term used to define the amount of virus in the body after the initial immune response subsides is
viral set point.
A client with HIV will be started on a medication regimen of three medications. What class of drugs will the nurse instruct the client about?
Reverse transcriptase inhibitors
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
A client taking fosamprenavir reports "getting fat." What is the nurse's best action?
Teach the client about medication side effects.
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse?
The client has converted from HIV infection to AIDS.
A client that is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?
Trimethoprim-sulfamethoxazole
A client has been diagnosed with HIV and has been placed on antiretroviral therapy. What does the nurse inform the client will be required for determining the progression of the disease as well as guiding drug therapy?
Viral load and T4-cell counts will be performed every 2 to 3 months.
In a client infected with human immunodeficiency virus (HIV), CD4+ levels are measured to determine the:
extent of immune system damage.
The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply.
semen breast milk blood vaginal secretions
A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client take for the treatment of this infection?
trimethoprim-sulfamethoxazole
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
Which term defines the balance between the amount of HIV in the body and the immune response?
Viral set point
A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?
Western blot assay
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.
