Chapter 19: Care of Patients with HIV Disease

Question 1

The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best?

Answer 1

Counsel the client on safer sex practices/abstinence

This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence.

Question 2

The nurse is presenting information to a community group on safer sex practices. The nurse should teach
that which sexual practice is the riskiest?

Answer 2

Anal intercourse

Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.

Question 3

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?

Answer 3

Consistent use of Standard Precautions

According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is
consistent use of Standard Precautions.

Question 4

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4
days ago. What action should the nurse take first?

Answer 4

Place the client under Airborne Precautions

Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune
response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB.

Question 5

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important?

Answer 5

Assess the clients sexual activity and patterns

The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the clients sexual behavior further to determine the proper response.

Question 6

A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?

Answer 6

Assess the client for adherence to the drug regimen

Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased dramatically, the nurse should first assess this factor.

Question 7

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?

Answer 7

Pace activities, allowing for adequate rest

This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should
not do everything for the client but rather let the client do as much as possible within limits and allow for
adequate rest in between.

Question 8

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem?

Answer 8

Has a weight gain of 2 pounds/1 month

The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrien

Question 9

A client with acquired immune deficiency syndrome (HIV-III) is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?

Answer 9

1. Adhering to Standard Precautions

2. Disposing of soiled dressings properly

Question 10

A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management?

Answer 10

Treatment is aimed at treating specific infections

Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins

Question 11

An HIV-positive (HIV-III) client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?

Answer 11

Use Standard Precautions/Protective Precautions. consistently

Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.

Question 12

A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and
does not know what to do. What intervention by the nurse is best?

Answer 12

Assess the client for support systems.

This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her

Question 13

A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The
nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best?

Answer 13

Confront the staff members about unethical behavior

The professional nurse should be able to confront unethical behavior assertively. The staff should not be
talking about clients unless they have a need to do so for client care

Question 14

A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome (HIV-III) . The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best?

Answer 14

Contact the social worker to assist the client with advance directives

The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process.

Question 15

A client with human immune deficiency virus infection (HIV-III) is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?

Answer 15

Consult with the pharmacy about drug interactions

The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be
given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions.

Question 16

A client with acquired immune deficiency syndrome/HIV-III has been hospitalized with suspected
cryptosporidiosis. What physical assessment would be most consistent with this condition?

Answer 16

Assessing mucous membranes

Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess
signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness

Question 17

A client with HIV-III/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best?

Answer 17

This drug helps treat the pain from nerve irritation

Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.

Question 18

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which
client should the nurse assess first?

Answer 18

Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C)

A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first

Question 19

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug?

Answer 19

Truvada does not reduce the need for safe sex prac

Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human
immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not
reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months.

Question 20

A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements aboutnHIV infection are correct? (Multiple Response)

Answer 20

CD4+ cells begin to create new HIV virus particles.

Opportunistic infections and cancer are leading causes of death

Macrophages stop functioning properly.

Antibodies produced are incomplete and do not function well.

In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

Question 21

Which findings are AIDS-defining characteristics? (Multiple Response)

Answer 21

CD4+ cell count less than 200/mm3 or less than 14%

Infection with Pneumocystis jiroveci

Presence of HIV wasting syndrome

Confusion, dementia, or memory loss

A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 (0.2 × 109/L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as P. jiroveci and HIV wasting syndrome. Confusion, dementia, and memory loss are central nervous system indications

Question 22

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? ( Mutltiple Response)

Answer 22

Clean drinking water
Cultural beliefs about illness
Lack of antiviral medication
Social stigma

Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

Question 23

A client with acquired immune deficiency syndrome (AIDS)/HIV-III is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Multiple Resposne)

Answer 23

Aspartate transaminase, alanine transaminase: elevated
Platelet count: 80,000/mm3
Serum sodium: 120 mEq/L

The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported.

Question 24

A client with acquired immune deficiency syndrome/HIV-III has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Multiple Response)

Answer 24

Assist the client with oral care every 2 hours.

Offer the client frequent sips of cool drinks.

Remind the client to use only a soft toothbrush.

Offer the client soft foods like gelatin or pudding.

The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used. Soft foods and liquids are tolerated better than harder foods

Question 25

A client with acquired immune deficiency syndrome/HIV-III is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Multiple Responsw)

Answer 25

Assisting the client to get out of bed to prevent falls

Obtaining a bedside commode if the client is weak

Providing gentle perianal cleansing after stools

Reporting any perianal abnormalities

The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open
areas

Question 26

A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Multiple Response)

Answer 26

Assess the clients mouth and throat.

Ensure that the consent form is on the chart.

Maintain NPO status as prescribed.

Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the
client in NPO status as prescribed.

Question 27

A nurse is caring for a client with HIV-III who was admitted with HAND. What sign or symptom would be most important for the nurse to report to the primary health care provider?

Answer 27

Change in pupil size

HIV-associated neurocognitive disorder (HAND) is a sign of neurologic involvement. The nurse would report any sign of increasing intracranial pressure immediately, including change in pupil size, level of consciousness, vital signs, or limb strength.

Question 28

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug?

Answer 28

Does not reduce the need for safe sex practices.

Tenofovir/emtricitabine is a newer drug used for preexposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months

Question 29

The nurse is teaching a client about medications for HIV-II treatment. What drugs are paired with the correct information? (Multiple Response)

Answer 29

Abacavir: avoid fatty and fried foods.

Efavirenz: take 1 hour before or 2 hours after antacids

All drugs: you must adhere to the drug schedule at least 90% of the time for effectiveness.

Abacavir is a nucleoside reverse transcriptase inhibitor and clients are taught to avoid fried and fatty foods because they can lead to
digestive upsets and even pancreatitis. Efavirenz is a nonnucleoside reverse transcriptase inhibitor and clients are taught to take them (doraverene) all except spaced 1 hour before or 2 hours after antacids to avoid inhibiting drug absorption. Atazanavir is a
protease inhibitor and can cause bradycardia which should be reported. Dolutegravir is an integrase inhibitor and can cause birth defects. Enfuvirtide is a fusion inhibitor and is given ubcutaneously. All drugs must be taken as scheduled 90% of the time in order to remain effective.

Question 30

The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low.
What information does the nurse provide? (Multiple Response)

Answer 30

Do not work in the garden or with houseplants.

Do not empty the kitty litter boxes.

Bathe daily using antimicrobial soap.

Avoid people who are sick and large crowds.

Make sure meat, fish, and eggs are cooked well.

Ways to avoid infection when immunocompromised include not working in the garden or with houseplants; not emptying litter
boxes; running the toothbrush through the dishwasher at least weekly; bathing daily using antimicrobial soap; avoiding sick people and large crowds; and making sure meat, fish, and eggs are cooked well prior to eating them

Question 31

A nurse is providing education about HIV risks at a health fair. What groups would the nurse include as needing to be tested for
HIV on an annual basis? (Multiple Response)

Answer 31

Couples planning on getting married

Those who are sexually active with multiple partners

Injection drugs users

Sex workers and their customers

The CDC recommends that HIV testing would be performed on those who received a transfusion between 1978 and 1985 only.
People planning on getting married should be tested and all sexually active people should know their HIV status. Those engaged in
sex work and their customers should also be tested, as well as injection drug users. Those over the age of 65 years need a one-time
screen.

Question 32

A nurse begins a job at a Veterans Administration Hospital and asks why so much emphasis is on HIV testing for the veterans. What reasons is this nurse given? (Multiple Response)

Answer 32

Veterans have a high prevalence of substance abuse.

Many veterans may engage in high risk behaviors.

Many older veterans may not know their risks.

Everyone should know their HIV status.

Belief that the VA has tested them and would notify them if positive.