Immune System: Saunders Flashcards
The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi’s sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding?
Positive punch biopsy of the cutaneous lesions
Rationale:
Kaposi’s sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.
Reference(s):
Ignatavicius, Workman, Rebar (2018), pp. 354-355.
The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine. The nurse interprets that the client may have the medication discontinued by the primary health care provider if which elevated result is noted?
Serum amylase level
Rationale:
Didanosine can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.
Reference(s):
Skidmore-Roth (2017), pp. 362-364.
A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while the client is taking this medication?
Gait
Rationale:
Stavudine is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client’s gait closely and ask the client about paresthesia.
Reference(s):
Skidmore-Roth (2017), pp. 1093-1094.
A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client?
Ensure that the client uses an electric razor for shaving.
Rationale:
Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy.
Reference(s):
Ignatavicius, Workman, Rebar (2018), p. 744.
A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102º F (38.9º C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition?
Infection caused by leukopenic effects of the medication
Rationale:
Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. Adverse effects of pentamidine include leukopenia, thrombocytopenia, and anemia. The client should be routinely assessed for signs and symptoms of infection.
Reference(s):
Gahart, Nazareno, Ortega (2019), pp. 1053-1054.
A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client?
A Western blot will be done to confirm these findings.
Rationale:
Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. If the result of the ELISA is positive, the Western blot is done to confirm the findings. If the result of the Western blot is positive, the client is considered to be seropositive for the infection and to be infected with the virus.
Reference(s):
Ignatavicius, Workman, Rebar (2018), p. 349.
The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation?
Cough
Rationale:
Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The client with P. jiroveci infection usually has a cough as the first sign. The cough begins as nonproductive and then progresses to productive. Later signs and symptoms include fever, dyspnea on exertion, and finally dyspnea at rest.
Reference(s):
Ignatavicius, Workman, Rebar (2018), pp. 346, 353.
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply.
Keep liquids at the bedside.
Place a towel over the pillowcase.
Make sure the pillow has a plastic cover.
Keep a change of bed linens nearby in case they are needed.
Rationale:
Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at the bedside to drink.
Reference(s):
Ignatavicius, Workman, Rebar (2018), pp. 353-354.
The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has begun to experience multiple opportunistic infections. Which laboratory test would be most helpful in assessing the client’s need for reassessment of treatment?
CD4+ cell or T lymphocyte count
Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The T lymphocyte or CD4+ cell count indicates whether the client is responding to the medication treatment. The count should increase if the client is responding and should decrease if the client’s response is poor. The Western blot and ELISA are tests to assist in diagnosing human immunodeficiency virus infection.
Reference(s):
Ignatavicius, Workman, Rebar (2018), pp. 338
A client reports to the health care clinic for testing for human immunodeficiency virus (HIV) immediately after being exposed to HIV. The test results are negative, and the client expresses relief about not contracting HIV. What should the nurse emphasize when explaining the test results to the client?
A negative HIV test result is not considered accurate immediately after exposure.
Rationale:
Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A test for HIV should be repeated if results are negative. Seroconversion is the point at which antibodies appear in the blood. The average time for seroconversion is 2 months, with a range of 2 to 10 months. For this reason, a negative HIV test result is not considered accurate immediately after exposure.
Reference(s):
Lewis et al. (2017), pp. 222, 227.
A client is admitted to the intensive care unit with suspected pheochromocytoma. The client’s vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min. The client is sweating profusely and reports a severe headache. Which prescription should the nurse implement first?
Start Nitroprusside infusion at 0.5mcg/kg/min
Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis.
Important points to note when caring for these clients include the following:
Hypertension is difficult to treat and is often resistant to multiple drugs.
The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver).
Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis.
Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter.
The nurse in the emergency department is caring for a client recently diagnosed with Graves’ disease who was admitted following a motor vehicle accident. The nurse notes the vital signs shown in the exhibit. The nurse alerts the primary health care provider that the client may be experiencing which condition?
Thyroid storm
Thyroid storm is a life-threatening condition that can occur in uncontrolled hyperthyroidism or Graves’ disease when a stressful incident, such as this client’s motor vehicle accident, triggers a sudden surge of thyroid hormone. Manifestations of thyroid storm include a rapid onset of fever, tachycardia, and elevated blood pressure. The client often feels anxious, tremulous, or restless. Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is necessary.
The nurse practicing in an out-patient clinic cares for a client recently diagnosed with hyperthyroidism. Which diet-related teaching should the nurse add to the client’s plan of care? Select all that apply.
