Prepu: Chapter 32 Cardiac
A nursing student assists a registered nurse to admit a client with a primary immunodeficiency. The nurse explains to the student that primary immunodeficiencies predispose people to three conditions. Which of the following three are those conditions?
Autoimmunity Severe infections Cancer
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.
Delavirdine Efavirenz
The nurse teaches the client that reducing the viral load will have what effect?
Longer survival
A client taking abacavir has developed fever and rash. What is the priority nursing action?
Report to the health care provider.
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.
A client suspected of having human immunodeficiency virus (HIV) asks the nurse what causes AIDS. What is the best response by the nurse?
The human immunodeficiency virus
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)
A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action?
Assess blood urea nitrogen and creatinine
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is
Malnutrition
A client with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this client?
Meticulous infection control precautions
A client with common variable immunodeficiency (CVID) comes to the ED reporting tingling and numbness in the hands and feet, muscle weakness, fatigue, and chronic diarrhea. An assessment reveals abdominal tenderness, weight loss, and loss of reflexes. A gastric biopsy shows lymphoid hyperplasia of the small intestine and spleen as well as gastric atrophy. Based on these findings, what common secondary problem has this client developed?
Pernicious anemia
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
Which of the following is the first barrier method that can be controlled by the woman?
Female condom
The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?
"The client may have cryptococcal meningitis and will need to be evaluated by the health care provider."
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 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
A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?
AIDS
A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?
Bank autologous blood.
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.
A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize what intervention?
Educational programs that focus on control and prevention
When describing the effects of treatment for phagocytic cell disorders, which of the following would the nurse include as being the most successful?
Hematopoietic stem cell transplantation
Which of the following indicates that a client with HIV has developed AIDS?
Herpes simplex ulcer persisting for 2 months
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started?
Immunosuppressive agents
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 with human immunodeficiency virus (HIV) develops a nonproductive cough, shortness of breath, a fever of 101°F and an O2 saturation of 92%. What infection caused by Pneumocystis jiroveci does the nurse know could occur with this client?
Pneumocystis pneumonia
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
A client with a primary immunodeficiency is undergoing genetic testing. This testing would be of least benefit in identifying which condition?
Severe combined immunodeficiency disease (SCID)
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family?
The importance of maintaining the client's vaccination status
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits what behavior?
The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
The term used to define the amount of virus in the body after the initial immune response subsides is
viral set point.
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."
A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection?
Follow the same sexual precautions as someone who has been diagnosed with AIDS.
Which type of phagocytic disorder occurs when white blood cells cannot initiate an inflammatory response to infectious organisms?
Hyperimmunoglobulinemia
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.