UNIT 2: Management of Patients with Immune Deficiency Disorders

Question 1

1. A client has just been diagnosed with a primary immune deficiency disease (PIDD). The client has done some research online and believes this is an unlikely diagnosis due to the client’s age. At which stage of life are people most commonly diagnosed with PIDD?
   A. Early childhood
   B. Infancy
   C. Adolescence
   D. Early adulthood

Answer 1

ANS: B
Rationale: The majority of PIDDs, which are a grouping of rare genetic disorders that impair the immune system, are commonly diagnosed in infancy, with a male to female ratio of 5 to 1. However, some PIDDs are not diagnosed until adolescence or early adulthood. There are more than 200 forms of PIDDs with 270 different genes associated with this condition.

Question 2

2. A client with Wiskott–Aldrich syndrome (WAS) is admitted to the medical unit. The nurse caring for the client should prioritize which intervention?
   A. Protective isolation
   B. Fresh-frozen plasma (FFP) administration
   C. Chest physiotherapy
   D. Nutritional supplementation

Answer 2

ANS: A
Rationale: Clients with WAS are at a grave risk for infection; infection prevention is a priority aspect of nursing care. Nutritional supplementation may be necessary, but infection prevention is paramount. Chest physiotherapy and FFP administration are not indicated.

Question 3

3. A pediatric nurse is working with an interdisciplinary team and parents to care for a 6-month-old client who has recently been diagnosed with severe combined immune deficiency (SCID). Which treatment is likely of most benefit to this client’s type of primary immune deficiency disease (PIDD)?
   A. Combined radiotherapy and chemotherapy
   B. Antibiotic therapy
   C. Hematopoietic stem cell transplantation (HSCT)
   D. Treatment with colony-stimulating factors (CSFs)

Answer 3

ANS: C
Rationale: HSCT is a curative modality for some PIDDs, such as SCID. The stem cells may be from embryos or adults. SCID’s onset is typically manifested by 6 months of age or earlier. SCID causes a child to be born with little or no immune system and historically resulted in frequent deaths due to multiple infections. Newborn screening in recent years has resulted in early inventions with HSCT and gene therapy. Radiation and chemotherapy, antibiotics, and CSF do not provide a cure.

Question 4

4. A nurse is implementing the care plan of diarrhea related to enteric pathogens of human immunodeficiency virus infections. Which interventions are needed to reach the goal of resuming usual bowel habits? Select all that apply.
   A. Administer antimicrobials.
   B. Restrict fluid to 1500 mL/50.7 fl oz daily.
   C. Implement a BRAT diet.
   D. Administer antitussives.
   E. Establish normal bowel pattern.

Answer 4

ANS: A, E

Rationale: After establishing the client’s normal pattern of bowel habits (i.e., frequency, time, consistency, color) and current problems (i.e., diarrhea, constipation, abdominal cramps/pain), a stool sample is then collected to identify any pathogenic organisms and any antimicrobial therapy needed. The BRAT (bananas, rice, applesauce, tea, and toast) diet is a type of bland diet that reduces stimulation/hyperactivity of the bowels. It is a temporary step. Unless contraindicated, clients are encouraged to maintain a fluid intake of 3L/0.793GL (3000 mL/1014 fl oz) daily to prevent hypovolemia. Antitussives are medications used to suppress cough and are not used to restore normal bowel patterns.

Question 5

5. The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply.
   A. Using appropriate personal protective equipment
   B. Placing clients in negative pressure isolation rooms
   C. Placing clients in positive pressure isolation rooms
   D. Using safe injection practices
   E. Performing hand hygiene

Answer 5

ANS: A, D, E

Rationale: Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions.

Question 6

6. A client with a diagnosis of primary immunodeficiency disease informs the nurse that the client has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the client’s vital signs are within reference ranges, what action should the nurse take?
   A. Administer a nebulized bronchodilator.
   B. Perform oral suctioning.
   C. Assess the client for signs and symptoms of infection.
   D. Teach the client deep breathing and coughing exercises.

Answer 6

ANS: C

Rationale: Dyspnea and cough are among the varied signs and symptoms that may suggest infection in an immunocompromised client. There is no indication for suctioning or the use of nebulizers. Deep breathing and coughing exercises do not address the client’s complaints or the likely etiology.

Question 7

7. A nurse caring for a client who has an immunosuppressive disorder knows that continual monitoring of the client is critical. What is the primary rationale behind the need for continual monitoring?
   A. So that the client’s functional needs can be met immediately
   B. So that medications can be given as prescribed and signs of adverse reactions noted
   C. So that early signs of impending infection can be detected and treated
   D. So that the nurse’s documentation can be thorough and accurate

Answer 7

ANS: C
Rationale: Continual monitoring of the client’s condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the client’s status. Continual monitoring is not primarily motivated by the client’s functional needs or medication schedule. The nurse’s documentation is important, but less so than infection control.

Question 8

nurse is planning the care of a client who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this client?
A. Administration of IVIG
B. Antibiotic administration
C. Appropriate use of gloves and goggles
D. Thorough and consistent hand hygiene

Answer 8

ANS: D
Rationale: Hand hygiene is usually considered the most important aspect of infection control. IVIG and antibiotics are not considered infection control measures, though they enhance resistance to infection and treat infection. Gloves and goggles are sometimes indicated but are less effective than hand hygiene.

Question 9

9. A home health nurse is caring for a client who has an immunodeficiency. What is the nurse’s priority action to help ensure successful outcomes and a favorable prognosis?
   A. Encourage the client and family to be active partners in the management of the immunodeficiency.
   B. Encourage the client and family to manage the client’s activity level and activities of daily living effectively.
   C. Make sure that the client and family understand the importance of monitoring fluid balance.
   D. Make sure that the client and family know how to adjust dosages of the medications used in treatment.

Answer 9

ANS: A

Rationale: Encouraging the client and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favorable prognosis. This transcends the client’s activity and functional status. Medications should not be adjusted without consultation from the primary provider. Fluid balance is not normally a central concern.

Question 10

10. Since the emergence of the human immunodeficiency virus (HIV), there have been significant changes in epidemiologic trends. At present, members of which group are most affected by new cases of HIV?
    A. Male-to-male sexual contact
    B. Heterosexual contact
    C. Male-to-male sexual contact with injection drug use
    D. People 25 to 29 years of age

Answer 10

ANS: A
Rationale: In the United States from 2012 to 2016, male-to-male sexual contact accounted for approximately 67% of new cases, male-to-male contact with injection use 3%, heterosexual contact 24%, and people 25 to 29 years of age 32.9%.

Question 11

11. A clinic nurse is caring for a client admitted with acquired immunodeficiency syndrome (AIDS). The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of which complication?
    A. Human immunodeficiency virus (HIV) encephalopathy
    B. B-cell lymphoma
    C. Kaposi sarcoma
    D. Wasting syndrome

Answer 11

ANS: A
Rationale: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. B-cell lymphoma is a type of non-Hodgkin lymphoma, and fatigue and weight loss are some typical signs and
symptoms. Kaposi sarcoma is a malignancy that impacts clients with HIV/AIDS and involves epithelial layers of blood and lymphatic vessels. Lesions on the skin and lymphedema can cause pain and infections. Wasting syndrome is related to HIV/AIDS and involves involuntary loss of 10% of total weight with diarrhea and fevers. None of the other listed complications normally have cognitive and behavioral manifestations.

Question 12

12. A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority?
    A. Oral temperature of 37.2°C (99°F)
    B. Tachypnea and restlessness
    C. Frequent loose stools
    D. Weight loss of 0.45 kg (1 lb) since yesterday

Answer 12

ANS: B

Rationale: In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 37.2°C (99°F) is not considered a fever and would not be the first issue addressed.

Question 13

13. A client has come into the free clinic asking to be tested for human immunodeficiency virus (HIV) infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the acquired immunodeficiency syndrome (AIDS) virus are present in the blood, this indicates that the client has which of the following?
    A. Immunity to HIV
    B. An intact immune system
    C. An AIDS-related complication
    D. An HIV infection

Answer 13

ANS: D

Rationale: Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications.

Question 14

14. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, which instruction should the nurse give the attendees?
    A. Apply the condom prior to erection.
    B. A condom may be reused with the same partner if ejaculation has not occurred.
    C. Use skin lotion as a lubricant if alternatives are unavailable.
    D. Hold the condom during withdrawal so it doesn’t come off.

Answer 14

ANS: D

Rationale: The condom should be held during withdrawal so it does not come off the
penis. The condom should be unrolled over the hard penis, not prior to erection, before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, and cold cream should not be used with condoms because they cause latex deterioration/condom breakage. Condoms should never be reused.

Question 15

15. A nurse is planning the care of a client with acquired immunodeficiency syndrome (AIDS) who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client?
    A. Ineffective airway clearance
    B. Impaired oral mucous membranes
    C. Imbalanced nutrition: Less than body requirements
    D. Activity intolerance

Answer 15

ANS: A
Rationale: Although all these nursing diagnoses are appropriate for a client with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the client with PCP. Airway and breathing take top priority over the other listed concerns because of the immediacy of the health consequences.

Question 16

16. A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold?

A. 75 cells/mm3 of blood
B. 200 cells/mm3 of blood
C. 325 cells/mm3 of blood
D. 450 cells/mm3 of blood

Answer 16

ANS: B
Rationale: When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.

Question 17

17. A client’s current antiretroviral regimen includes enfuvirtide (T-20). What dietary counseling will the nurse provide based on the client’s medication regimen?
    A. Avoid high-fat meals while taking this medication.
    B. Limit fluid intake to 2 L/day.
    C. Limit sodium intake to 2 g/day.
    D. Take this medication without regard to meals.

Answer 17

ANS: D

Rationale: Enfuvirtide (T-20) is injected subcutaneously, so meals are not an important variable. Protein, sodium, and fluid levels are not significant.

Question 18

18. A nurse is performing an admission assessment on a client with stage 3 human immunodeficiency virus (HIV). After assessing the client’s gastrointestinal system and analyzing the data, which nursing diagnosis is most likely to be the priority?
    A. Acute abdominal pain
    B. Diarrhea
    C. Bowel incontinence
    D. Constipation

Answer 18

ANS: B
Rationale: Diarrhea is a problem in many clients with HIV and acquired immunodeficiency syndrome. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply.

Question 19

19. A client with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?
    A. “Complementary therapies generally have not been approved, so clients are usually discouraged from using them.”
    B. “Researchers have not looked at the benefits of alternative therapy for clients with HIV, so we suggest that you stay away from these therapies until there is solid research data available.”
    C. “Many clients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks.”
    D. “You’ll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach.”

Answer 19

ANS: C
Rationale: The nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach, emphasizing the need to communicate with care providers. Complementary therapies and medical treatment are not mutually exclusive, though some contraindications exist. Research supports the efficacy of some forms of complementary and alternative treatment.

Question 20

20. A client with HIV infection has begun experiencing severe diarrhea. What is the most
    appropriate nursing intervention to help alleviate the diarrhea?
    A. Administer antidiarrheal medications on a scheduled basis, as prescribed.
    B. Encourage the client to eat three balanced meals and a snack at bedtime.
    C. Increase the client’s oral fluid intake.
    D. Encourage the client to increase his or her activity level.

Answer 20

ANS: A

Rationale: Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis, provided the client’s diarrhea is not caused by an infectious microorganism. Increased oral fluid may exacerbate diarrhea; IV fluid replacement is often indicated. Small, more frequent meals may be beneficial, and it is unrealistic to increase activity while the client has frequent diarrhea.

Question 21

21. A nurse is caring for a client hospitalized with AIDS. A friend comes to visit the client and privately asks the nurse about the risk of contracting HIV when visiting the client. What is the nurse’s best response?
    A. “Do you think that you might already have HIV?”
    B. “Your immune system is likely very healthy.”
    C. “AIDS isn’t transmitted by casual contact.”
    D. “You can’t normally contract AIDS in a hospital setting.”

Answer 21

ANS: C
Rationale: AIDS is commonly transmitted by contact with blood and body fluids. Clients, family, and friends must be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV infection.

Question 22

22. A health care provider is taking post-exposure prophylaxis (PEP) medications for exposure to a client with human immunodeficiency virus (HIV). Which topics will the health care provider need to understand regarding PEP administration prior to beginning this regimen? Select all that apply.
    A. Potential drug toxicities
    B. Needed dietary changes
    C. Potential drug interactions
    D. Sleep pattern disturbances
    E. Adherence requirements

Answer 22

ANS: A, C, E
Rationale: The health care provider will need to understand potential drug toxicities, such as rashes and hypersensitivity reactions, which could imitate acute HIV seroconversion and require monitoring. The health care provider will also need to understand potential drug interactions, such as with supplements and vitamins, which could change the effectiveness of PEP. The health care provider will also need to understand adherence requirements, as adherence to the daily use of the PEP is paramount to its effectiveness. Typically, for most of PEP, there are no specific dietary changes needed. Sleep pattern disturbances generally do not happen with administration of these medications.

Question 23

23. An 18-year-old client who is pregnant has tested positive for human immunodeficiency virus (HIV) and asks the nurse if her baby is going to be born with HIV. Which response by the nurse is the best?
    A. “Your baby has a one in four chance of being born with HIV.”
    B. “Your health care provider is likely the best one to answer that question.”
    C. “If the baby is HIV-positive, we can’t do anything until after the birth, so try not to worry.”
    D. “Your baby could contract HIV before, during, or after delivery.”

Answer 23

ANS: D
Rationale: Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breastfeeding. There is no evidence that the infant’s risk is 25%. Deferral to the health care provider is not a substitute for responding appropriately to the client’s concern. Downplaying the client’s concerns is inappropriate.

Question 24

24. On admission to a medical unit, a client with human immunodeficiency virus (HIV) tests positive for benzodiazepine. The client denies using this medication. Which medication is likely causing a false-positive result?
    A. Efavirenz
    B. Doravirine
    C. Nevirapine
    D. Etravirine

Answer 24

ANS: A
Rationale: Use of efavirenz, even as part of a combination drug, may lead to
false-positive results with cannabinoid and benzodiazepine screening assays. Efavirenz, doravirine, nevirapine and etravirvine are all non-nucleoside reverse transcriptase inhibitors that bind and block the HIV enzyme and prevent replication in the body.
Doravirine, nevirapine, and etravirvine do not have the adverse side effect of false-positives for cannabinoid and benzodiazepine.

Question 25

25. A client is in the primary infection stage of human immunodeficiency virus (HIV). Which statement regarding this client’s current health status is most accurate?
    A. The client’s HIV antibodies are successfully, but temporarily, killing the virus.
    B. The client is infected with HIV but lacks HIV-specific antibodies.
    C. The client’s risk for opportunistic infections is at its peak.
    D. The client may or may not develop long-standing HIV infection.

Answer 25

ANS: B

Rationale: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection
is certain. Opportunistic infections emerge much later in the course of the disease.

Question 26

26. A client’s primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the client’s immune response. This is known as what physiologic state?
    A. Static stage
    B. Latent stage
    C. Viral set point
    D. Window period

Answer 26

ANS: C
Rationale: The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though they are infected.

Question 27

27. A client with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education?
    A. Appropriate use of prophylactic antibiotics
    B. Importance of personal hygiene
    C. Signs and symptoms of wasting syndrome
    D. Strategies for adjusting antiretroviral dosages

Answer 27

ANS: B
Rationale: Infection control is of high importance in clients living with HIV, thus personal hygiene is paramount. This is a more important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be independently adjusted. Prophylactic antibiotics are not normally prescribed unless the client’s CD4+ count is below 50.

Question 28

28. A female client who is HIV negative arrives for a gynecologist appointment and reports that her husband, who is HIV positive, no longer wants to wear a latex condom. Which alternative treatments would the nurse recommend to reduce the likelihood of HIV transmission? Select all that apply.
    A. Dental dam
    B. Polyurethane female condom
    C. Microbicidal vaginal suppository
    D. Non-latex male condoms
    E. Pre-exposure prophylaxis

Answer 28

ANS: A, B, E
Rationale: A dental dam, which is a flat piece of latex, can be used for oral contact with the vagina or penis. A polyurethane female condom is an effective contraceptive and also effective in preventing the transmission of HIV. Pre-exposure prophylaxis involves one pill containing 2 HIV medications daily to prevent HIV conversion. A microbicidal vaginal suppository is currently not a reality, although clinical trials are occurring.
Non-latex/lambskin male condoms will not protect the client from HIV due to permeability. Breakage is usually related to polyurethane condoms, which are more
effective than lambskin.

Question 29

29. A client has come into contact with HIV. As a result, HIV glycoproteins have fused with the client’s CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle?
    A. Integration
    B. Attachment
    C. Cleavage
    D. Budding

Answer 29

ANS: B
Rationale: During the process of attachment, glycoproteins of HIV bind with the host’s uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle.

Question 30

30. A client with human immunodeficiency virus (HIV) is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this client should expect the health care provider to prescribe which medication for the management of the client’s diarrhea?
    A. Fluoxetine
    B. Octreotide acetate
    C. Levofloxacin
    D. Valganciclovir

Answer 30

ANS: B
Rationale: Therapy with octreotide acetate, a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. Fluoxetine is an antidepressant and would not be prescribed for the treatment of chronic diarrhea.
Levofloxacin is an antibiotic and would not likely be prescribed for chronic severe diarrhea. Valganciclovir is an antiviral medication that is used to treat cytomegalovirus infection and would not be prescribed to treat chronic diarrhea.

Question 31

31. A client with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in clients with AIDS by increasing body fat stores?
    A. Psyllium
    B. Momordica charantia
    C. Megestrol
    D. Ranitidine

Answer 31

ANS: C
Rationale: Megestrol acetate, a synthetic oral progesterone preparation, promotes significant weight gain. In clients with HIV infection, it increases body weight primarily by increasing body fat stores. Psyllium is a fiber source. Momordica charantia (bitter melon) is given as an enema and is part of alternative treatment for HIV/AIDS. Ranitidine was previously used to prevent ulcers but was removed from the market in April 2020.

Question 32

32. A nurse is completing the nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
    A. Serum albumin level
    B. Weight history
    C. White blood cell count
    D. Body mass index
    E. Blood urea nitrogen (BUN) level

Answer 32

ANS: A, B, D, E
Rationale: Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the client’s ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment.

Question 33

33. A nurse is assessing the skin integrity of a client who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
    A. Perianal region and oral mucosa
    B. Sacral region and lower abdomen
    C. Scalp and skin over the scapulae
    D. Axillae and upper thorax

Answer 33

ANS: A
Rationale: The nurse should inspect all the client’s skin surfaces and mucous membranes, but the oral mucosa and perianal region are particularly vulnerable to skin breakdown and fungal infection.

Question 34

34. During a code blue, a nurse sustained a needlestick injury from a client whose human immunodeficiency virus (HIV) status was unknown. The nursing supervisor is notified, an incident report is generated, and a post–HIV exposure prophylaxis checklist is started for this nurse. In which order would the checklist be implemented?

A. Administer post-exposure prophylaxis (PEP) medication.
B. Advise exposed health care providers to use precautions.
C. Get counseling at the time of exposure.
D. Undergo early reevaluation after exposure.
E. Determine the HIV status of the client.

Answer 34

ANS: E, C, B, A, D

Rationale : It is important to determine the client’s HIV status through rapid testing (if possible) to help guide the appropriate use of PEP medications (as needed). The nurse should receive counseling at the time of exposure. Part of that counseling is to advise the nurse (health care provider) to use precautions (barrier conception, avoid blood donation, pregnancy and breast-feeding) to prevent secondary transmission. PEP
medication (if needed) then is given. And the nurse (in this case) is recommended to undergo early reevaluation within 72 hours after exposure.

Question 35

35. A nurse is providing ongoing care for a client who is positive for human immunodeficiency virus (HIV), and assessment reveals a client with a newly delayed and shortened speech pattern. The client, who previously had no neurological or motor deficits, has forgotten that they are in the hospital and has trouble getting out of bed. Which problem is the client most likely experiencing related to these signs and symptoms?
    A. Cryptococcal meningitis
    B. Cytomegalovirus retinitis
    C. Peripheral neuropathy
    D. Subcortical neurodegenerative disease

Answer 35

ANS: D
Rationale Subcortical neurodegenerative disease is known as HIV-associated neurocognitive disorder (HAND). Signs can be subtle and include changes in language, memory, and problem solving, as well as slowing psychomotor skills. Early identification is important as HAND can be treated by changing antiretroviral medications.
Cryptococcal meningitis is a form of subacute meningitis. Signs include fever, malaise, and headache. Retinitis caused by cytomegalovirus retinitis is the leading cause of blindness in clients with acquired immunodeficiency syndrome. Peripheral neuropathy is a common neurological symptom at any stage of HIV infection. Signs and symptoms are pain in the feet and functional impairment.

Question 36

36. A client has a diagnosis of AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate?
    A. Position the client in the high Fowler position whenever possible.
    B. Temporarily eliminate animal protein from the client’s diet.
    C. Make sure the client eats at least two servings of raw fruit each day.
    D. Obtain a stool culture to identify possible pathogens.

Answer 36

ANS: D

Rationale: A stool culture should be obtained to determine the possible presence of microorganisms that cause diarrhea. Clients should generally avoid raw fruit when having diarrhea. There is no need to avoid animal protein or increase the height of the bed.

Question 37

37. A client who has acquired immunodeficiency syndrome (AIDS) has been admitted for the treatment of Kaposi sarcoma. Which nursing diagnosis should the nurse associate with this complication of AIDS?
    A. Risk for disuse syndrome related to Kaposi sarcoma
    B. Impaired skin integrity related to Kaposi sarcoma
    C. Diarrhea related to Kaposi sarcoma
    D. Impaired swallowing related to Kaposi sarcoma

Answer 37

ANS: B
Rationale: Kaposi sarcoma is a type of cancer caused by human herpesvirus-8 that
involves the epithelial layer of blood and lymphatic vessels. It exhibits a variable and aggressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems. Cutaneous signs, which may be the first manifestation of HIV, can appear anywhere on the body and are usually brownish pink to deep purple. They may be flat or raised and surrounded by ecchymosis (hemorrhagic patches) and edema. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome.

Question 38

38. A nurse is performing the admission assessment of a client who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.
    A. Current medication regimen
    B. Identification of client’s support system
    C. Immune system function
    D. Genetic risk factors for HIV
    E. History of sexual practices

Answer 38

ANS: A, B, C, E
Rationale: Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function, and sexual history. HIV does not have a genetic component.

Question 39

39. A client underwent an antibody test for human immunodeficiency virus (HIV) as part of a screening process and has just been told that the results were positive. Which anticipatory guidance regarding the next step should the nurse provide to the client?
    A. The client will be started on fluoxetine in 1 month.
    B. Antiretroviral therapy will begin within 3 months.
    C. Follow-up testing will be promptly performed to confirm the result.
    D. The client will be monitored for signs and symptoms of HIV to determine the need for treatment.

Answer 39

ANS: C

Rationale: Follow-up testing is performed if the initial test result is positive to ensure a correct diagnosis. These tests include antibody differentiation tests, which distinguish HIV-1 from antibodies, and HIV-1 nucleic acid tests, which look for the virus RNA directly. Antiretroviral therapy may be needed, but the next step would be to confirm the diagnosis. Fluoxetine, an antidepressant, would be prescribed if the client developed severe depression, which is not evident in this scenario. The client would not simply be monitored for signs and symptoms of HIV to determine treatment; the client would undergo follow-up testing to determine the need for treatment.