PrepU Chapter 36
During assessment of a patient with Kaposi's sarcoma, the nurse knows to look for the initial sign of:
Deep purple cutaneous lesions.
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
The nurse is caring for a client whose most recent laboratory values reveal a neutrophil level of 21,000 mm3. When preparing to assess the client, the nurse should prioritize what assessment?
Assessing the client for signs and symptoms of infection
Which of the following are modes of transmission for HIV? Select all that apply.
Blood Seminal fluid Vaginal secretions Amniotic fluid
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 is diagnosed with severe combined immunodficiency (SCID). Which of the following would the nurse expect to integrate into the client's plan of care?
Preparation for bone marrow transplantation
The nurse is caring for a client with an autoimmune disease. What is a characteristic of autoimmune disorders?
Progressive tissue damage without any verifiable etiology
A client taking abacavir has developed fever and rash. What is the priority nursing action?
Report to the health care provider
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?
Stool specimen for ova and parasites
Thirty minutes after the nurse begins an intravenous immunoglobulin (IVIG) infusion, the client reports itching at the site and a lump in the throat. Which action should the nurse take first?
Stop the infusion.
Kaposi sarcoma (KS) is diagnosed through
biopsy.
A client with human immunodeficiency virus undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:
the client is immunodeficient and won't have a skin response.
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."
A patient with 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 patient has developed?
Candidiasis
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.
Which of the following is the first barrier method that can be controlled by the woman?
Female condom
Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?
Liquids
HIV is harbored within which type of cell?
Lymphocyte
When a nurse infuses gamma globulin intravenously, the rate should not exceed
3 mL/min
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation
A client with AIDS is brought to the clinic by their family. The family tells the nurse the client has become forgetful, with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?
HIV encephalopathy
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is
Malnutrition
A nurse knows that more than 50% of clients with CVID develop the following disorder
Pernicious anemia
Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?
Vascular lesions
A client with HIV will be started on a medication regimen of three medications. What drug will the nurse instruct the client about?
Reverse transcriptase inhibitors
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 containing the genetic viral material?
Ribonucleic acid (RNA)
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
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 male client comes to the walk-in clinic stating he has just found out he has been exposed to HIV. The client tests HIV-negative after an enzyme-linked immunosorbent assay test. The client wants to know the precise sources through which the HIV infection is transmitted, as he wants to take proper precautions. Which of the following body fluids transmits the HIV infection?
Semen
You are caring for a client who has a diagnosis of 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
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
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
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 with suspected HIV has had two positive enzyme-linked immunosorbent assay tests. What diagnostic test would be run next?
Western Blot
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
The nurse receives a phone call at the clinic from the family of a patient with AIDS. They state that the patient started "acting funny" after complaining of 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 patient may have cryptococcal meningitis and will need to be evaluated by the physician."
Antiretroviral medications should be offered to clients with T-cell counts less than
350 cells/mm3.
A client being treated for HIV/AIDS has a decreased appetite, almost to the point of anorexia. What is the best action by the nurse?
Administer megestrol acetate.
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.
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 of the following symptoms? Choose all that apply.
Flank pain Shaking chills Tightness in the chest
A majority of clients with CVID develop which type of anemia?
Pernicious
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