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39 Terms

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?

Infancy

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2

A client with Wiskott–Aldrich syndrome (WAS) is admitted to the medical unit. The nurse caring for the client should prioritize which intervention?

Protective isolation

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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)?

Hematopoietic stem cell transplantation (HSCT)

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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.

Administer antimicrobials, Administer antitussives, Administer antitussives

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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

Using appropriate personal protective equipment, Using safe injection practices, Performing hand hygiene

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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?

Assess the client for signs and symptoms of infection.

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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?

So that early signs of impending infection can be detected and treated

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8

A 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?

Thorough and consistent hand hygiene

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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?

Encourage the client and family to be active partners in the management of the immunodeficiency.

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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?

Male-to-male sexual contact

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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?

Human immunodeficiency virus (HIV) encephalopathy

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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?

Tachypnea and restlessness

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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?

An HIV infection

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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?

Hold the condom during withdrawal so it doesn’t come off.

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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?

Ineffective airway clearance

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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?

200 cells/mm3 of blood

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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?

Take this medication without regard to meals.

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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?

Diarrhea

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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?

"Many clients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks."

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20

A client with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?

Administer antidiarrheal medications on a scheduled basis, as prescribed.

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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?

"AIDS isn't transmitted by casual contact."

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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

Potential drug toxicities, Potential drug interactions, Adherence requirements

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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?

“Your baby could contract HIV before, during, or after delivery."

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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?

Efavirenz

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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?

The client is infected with HIV but lacks HIV-specific antibodies.

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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?

Viral set point

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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?

Importance of personal hygiene

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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

Dental dam, Polyurethane female condom, Pre-exposure prophylaxis

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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?

Attachment

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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?

Octreotide acetate

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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?

Megestrol

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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

Serum albumin level, Weight history, White blood cell count, Body mass index, Blood urea nitrogen (BUN) level

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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?

Perianal region and oral mucosa

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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.

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

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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?

Subcortical neurodegenerative disease

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36

A client has a diagnosis of AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate?

Obtain a stool culture to identify possible pathogens

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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?

Impaired skin integrity related to Kaposi sarcoma

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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

Current medication regimen, Identification of client's support system, Immune system function, History of sexual practices

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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?

Follow-up testing will be promptly performed to confirm the result.

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