Test 6 (HIV)

The nurse is assessing a patient who is diagnosed with human immunodeficiency virus (HIV) who presents with a rash. Which assessment question is most appropriate? 1) "Are you taking Bactrim?" 2) "Have you recently used a new soap?" 3) "What have you eaten in the last few days?" 4) "Did you have unprotected sex within the last week?"

1) "Are you taking Bactrim?" A new onset rash for a patient diagnosed with HIV is often a delayed reaction to a prophylactic antibiotic, such as Bactrim. This question is the most appropriate.

The nurse is caring for a patient who is newly diagnosed with human immunodeficiency virus (HIV). The patient asks the nurse if there are ways to protect the patient's life partner from getting the HIV virus. After educating the patient, which statement indicates the need for further education? 1) "I know to use an oil-based lubricant to prevent spread of the disease to my partner." 2) "I can still kiss and hug my partner to show affection." 3) "I will not share my razor with my partner." 4) "I know I have to practice safer sex with my partner by using a latex condom."

1) "I know to use an oil-based lubricant to prevent spread of the disease to my partner." The nurse should educate the patient on methods that will decrease the risk of transmitting the HIV. The patient statement regarding the use of an oil-based lubricant requires further education. The patient should use only water-based lubricants, not oil- based, such as petroleum jelly, which can result in condom damage.

The nurse is providing care to a pediatric patient who is HIV-positive. The patient's mother is describing the child's current condition and activities to the nurse. Which parental statement indicates that the child may require further intervention? 1) "My child seems somewhat isolated and doesn't have any real friends." 2) "My child has a good appetite and eats regular meals." 3) "My child hasn't shown any sign of infection." 4) "My child attends school and doing well in class."

1) "My child seems somewhat isolated and doesn't have any real friends." This statement indicates that the patient is not adequately coping with the current situation and requires further assessment and/or intervention by the nurse.

The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is in antiretroviral therapy. The patient reports nausea, fever, severe diarrhea, and anorexia. Which prescribed medication does the nurse anticipate in order to relieve the anorexia and to stimulate the patient's appetite? 1) Dronabinol (Marinol) 2) Abacavir (Ziagen) 3) Ciprofloxacin (Cipro) 4) Zidovudine (Retrovir, AZT)

1) Dronabinol (Marinol) Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase patient appetite and promote weight gain.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient presents with a fever without other notable symptoms. Which is the most likely cause of this data? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

1) Infection A fever is caused by infection.

A patient diagnosed with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor. Which stance regarding the care for this patient is supported by the American Nurses Association (ANA) Code of Ethics? 1) The nurse is morally obligated to care for the patient unless the risk exceeds responsibility. 2) The nurse has the responsibility to ensure the patient gets adequate medical care. 3) The patient has the right to choose not to disclose his or her condition to staff. 4) The patient is morally bound to disclose every aspect of his or her condition to staff.

1) The nurse is morally obligated to care for the patient unless the risk exceeds responsibility. According to the ANA Code of Ethics, the nurse cannot set aside the moral obligation to care for the patient infected with human immunodeficiency virus (HIV) unless the risk exceeds the responsibility.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is less than 200 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

1) Toxoplasmosis Toxoplasmosis is a complication that occurs when the patient's CD4+ count drops below 200 cells/L. This complication typically indicates the patient has progressed from HIV to acquired immunodeficiency syndrome (AIDS).

The nurse is discharging a pediatric patient who was recently diagnosed with acquired immunodeficiency syndrome (AIDS). When discussing appropriate health promotion activities for this child, which immunization is contraindicated? 1) Varicella vaccine 2) Haemophilus influenzae type B (HIB conjugate vaccine) 3) Hepatitis B vaccine (hep B) 4) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)

1) Varicella vaccine A child with an immune disorder such as HIV/AIDS should not be immunized with a live varicella vaccine, because of the risk of contracting the disease.

Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care? 1) Washing the injury under running water 2) Squeezing the site to remove the patient's blood 3) Taking two or three drugs for 28 days 4) Consenting to a human immunodeficiency virus (HIV) test

1) Washing the injury under running water The priority nursing action in this situation is to wash the injury under running water.

An adult patient is diagnosed with fibromyalgia. The patient asks the nurse whether a recent of infection with the Coxsackie B virus could have caused fibromyalgia. Which response by the nurse is the most appropriate? 1) "The Coxsackie B virus has nothing to do with fibromyalgia." 2) "The Coxsackie B virus may have triggered the fibromyalgia." 3) "The Coxsackie virus definitely caused the fibromyalgia." 4) "Fibromyalgia is a psychiatric disorder."

2) "The Coxsackie B virus may have triggered the fibromyalgia." The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus (HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia.

A home health nurse is conducting home visits for several patients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which patient would the nurse see first? 1) A patient who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell count 2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath 3) A patient with wasting syndrome who needs modifications and education regarding dietary changes 4) A patient who is receiving IV antibiotics daily for toxoplasmosis

2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath This patient needs to be seen by the nurse; however, based on the ABCs (airway, breathing, and circulation) this patient is not the priority.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a teaching session for this patient regarding this occurrence? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

2) Disease progression Weight loss is generally caused by worsening of the disease or disease progression.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 480 cells/mL. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

2) Herpes zoster virus Herpes zoster virus is a complication that occurs when the patient's CD4+ is between 500 and 350 cells/mL.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 500 cells/mL. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

2) Stage 1 Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/mL.

The nurse is reviewing the laboratory values of a patient who is newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which values should be reported to the patient's health-care provider? Select all that apply. 1) CD4 cell count 1,100/mm3 2) T4 cell count 150 3) CD4 lymphocytes 12% 4) Viral load 11,500 copies/mL 5) WBC 6,500

2) T4 cell count 150 3) CD4 lymphocytes 12% 4) Viral load 11,500 copies/mL

The nurse is planning care for a pediatric patient diagnosed with human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric patient. Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply. 1) Administering tuberculosis skin tests every six months 2) Teaching proper food-handling techniques to the family 3) Instructing on the importance of consuming ample fresh fruits and vegetables 4) Assessing the health status of all visitors 5) Monitoring hand-washing techniques used by the family

2) Teaching proper food-handling techniques to the family 4) Assessing the health status of all visitors 5) Monitoring hand-washing techniques used by the family 2) This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. 4) This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection. 5) This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. The nurse teaches the family to keep those who have symptoms of illness away from the child and also instructs them in proper hand-washing technique and proper food handling to prevent infection

The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement indicates that additional teaching is needed? 1) "I can't get the influenza vaccine due to my allergy to eggs." 2) "I will get the influenza vaccine every year." 3) "I will get the pneumococcal vaccine every fall." 4) "I will get the pneumococcal vaccine as soon as I recover from this pneumonia."

3) "I will get the pneumococcal vaccine every fall." The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had splenectomies, those with malignancies, and those with HIV/AIDS.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Which patient statement indicates the need for further education regarding HIV management? 1) "I will eat small, frequent meals." 2) "I will use condoms for every sexual encounter." 3) "I will take my medications when others can see me, even if that means taking them late." 4) "I will ask my spouse to clean the cat litter to decrease my risk for developing toxoplasmosis."

3) "I will take my medications when others can see me, even if that means taking them late." Adherence is essential in managing the progression of the disease. Taking medications as ordered and at the same time each day (plan administration times around activities of daily living) helps maintain therapeutic drug levels and decreases the risk of viral resistance developing.

Which function of white blood cells (WBCs) should the nurse include in a teaching session for the family of a pediatric patient who is diagnosed with human immunodeficiency virus (HIV)? 1) Carry oxygen from the lungs to the tissues 2) Return carbon dioxide from the tissues to the lungs 3) Assist the body to fight infection and allergens 4) Form hemostatic plugs to stop bleeding

3) Assist the body to fight infection and allergens A function of the WBCs is to fight infection and allergens.

A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus (HIV). The patient states, "I don't plan on giving up sex just because I am HIV positive." Based on this data, which is the priority nursing diagnosis for this patient? 1) Risk for Infection 2) Death Anxiety 3) Deficient Knowledge 4) Social Isolation

3) Deficient Knowledge While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient Knowledge due to the patient statement, "I don't plan on giving up sex just because I am HIV positive." The patient requires education regarding safer sex practices to decrease the risk of transmission to potential sexual partners.

Which immunization should the nurse encourage for a patient who is diagnosed with Stage 2 human immunodeficiency virus? 1) Measles, mumps, and rubella (MMR) vaccine 2) Oral polio vaccine (OPV) 3) Influenza vaccine 4) Varicella vaccine

3) Influenza vaccine The influenza vaccine is not a live virus vaccine and is recommended annually, early in the flu season, for patients with HIV.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient reports night sweats. Which is the most likely reason for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

3) Mycobacterial infection Night sweats are caused by a mycobacterial infection.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of 300 cells/mL. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 N 3) Stage 2 4) Stage 3

3) Stage 2 Stage 2 is documented for a patient with a CD4+ count of 200-499 cells/mL.

A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement when providing direct care? 1) Droplet 2) Reverse 3) Standard 4) Contact

3) Standard Health-care workers can prevent most exposures to HIV by using standard precautions. With standard precautions, the health-care professionals treat all patients alike, eliminating the need to know their HIV status. Treat all high-risk body fluids as if they are infectious, and use barrier precautions to prevent skin, mucous membrane, orpercutaneous exposure to these fluids.

Which is not a warning sign of a sexually transmitted infection (STI)? 1) Penile discharge 2) Penile lesion 3) Testicular mass 4) Dysuria

3) Testicular mass A testicular mass is not a clinical manifestation associated with an STI. A testicular mass may be benign or malignant.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is greater than 500 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

3) Vaginal candidiasis Vaginal candidiasis is a complication that occurs when the patient's CD4+ count is greater than 500 cells/mL.

The nurse is providing care to a pregnant patient with a history of drug use. The patient refuses testing for human immunodeficiency virus (HIV) despite the recommendation of her nurse-midwife. Which actions by the nurse are appropriate in this situation? Select all that apply. 1) Refusing to treat the patient unless she is tested 2) Running the test without the patient's knowledge 3) Emphasizing the importance of the test to the patient 4) Offering counseling regarding the testing 5) Encouraging the patient to reconsider the decision to be tested throughout the pregnancy

3. This is correct. SuggestiNng counseling and consistently encouraging testing are recommended. 4. This is correct. Suggesting counseling and consistently encouraging testing are recommended. 5. This is correct. Suggesting counseling and consistently encouraging testing are recommended.

A nurse is performing an admission assessment on a patient with symptoms that indicate human immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting HIV? 1) "Has your partner been experiencing these symptoms?" 2) "When was your first sexual experience?" 3) "Have you had any fever, diarrhea, or chills over the last 48 hours?" 4) "Have you ever experimented with intravenous drugs?"

4) "Have you ever experimented with intravenous drugs?" One risk factor for contracting HIV is the use of intravenous recreational drugs. This question is appropriate to determine the patient's risk for HIV.

Which patient should the nurse offer the opportunity for human immunodeficiency virus (HIV) testing during an annual physical examination? 1) A 66-year-old male patient 2) A 75-year-old female patient 3) An 8-year-old school-age child 4) An 18-year-old young adult patient

4) An 18-year-old young adult patient The nurse offers HIV testing to all patients between the ages of 15 years and 65 years of age.

The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The patient has shortness of breath when walking, but no problems breathing at rest. Which is the most likely cause for this clinical manifestation? 1) Infection 2) Disease progression 3) Mycobacterial infection 4) Pneumocystis carinii pneumonia

4) Pneumocystis carinii pneumonia Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.

The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The patient's CD4+ count is currently 250 cells/L. Which complication is this patient at risk for developing? 1) Toxoplasmosis 2) Herpes zoster virus 3) Vaginal candidiasis 4) Severe bacterial infection

4) Severe bacterial infection Severe bacterial infection is a complication that occurs when the patient's CD4+ is 350 and 200 cells/mL.

The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+ count of less than 200 cells/mL. Which classification of HIV should the nurse document for this patient? 1) Stage 0 2) Stage 1 3) Stage 2 4) Stage 3

4) Stage 3 Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/mL.