Deck 36: Management of Patients With Immune Deficiency Disorders

Question 1

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV?

A) Gay, bisexual, and other men who have sex with men
B) Recreational drug users
C) Blood transfusion recipients
D) Health care providers

Answer 1

Gay, bisexual, and other men who have sex with men

Question 2

A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient 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 what complication?

A) HIV encephalopathy
B) B-cell lymphoma
C) Kaposis sarcoma
D) Wasting syndrome

Answer 2

HIV encephalopathy

Question 3

A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?

A) Oral temperature of $100 \mathrm{~F}$
B) Tachypnea and restlessness
C) Frequent loose stools
D) Weight loss of 1 pound since yesterday

Answer 3

Tachypnea and restlessness

Question 4

A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what?

A) The patient is immune to HIV.
B) The patients immune system is intact.
C) The patient has AIDS-related complications.
D) The patient has been infected with HIV.

Question 5

A hospital patient is immunocompromised because of stage $3 \mathrm{HIV}$ infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test?

A) Arrange for a portable $\mathrm{x}$ -ray machine to be used.
B) Have the patient wear a mask to the x-ray department.
C)Ensure that the radiology department has been disinfected prior to the test.
D) Send the patient to the x-ray department, and have the staff in the department wear masks.

Question 6

The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?

A) Would you like me to have the chaplain come speak with you?
B) Youll learn much about the promise of a cure for HIV.
C) Can you tell me what concerns you most about dying?
D) You need to maintain hope because you may live for several years.

Question 7

The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?

A) Attach 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 by the cuff upon withdrawal.

Question 8

A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?

A) Ineffective Airway Clearance
B) Impaired Oral Mucous Membranes
C) Imbalanced Nutrition: Less than Body Requirements
D) Activity Intolerance

Question 9

A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions?

A) Lifestyle actions that improve immune function
B) Educational programs that focus on control and prevention
C) Appropriate use of standard precautions
D) Screening programs for youth and young adults

Question 10

A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold?

A) 75 cells $/ \mathrm{mm}^{3}$ of blood
B) 200 cells $/ \mathrm{mm}^{3}$ of blood
C) 325 cells $/ \mathrm{mm}^{3}$ of blood
D) 450 cells $/ \mathrm{mm}^{3}$ of blood

Question 11

During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?

A) Salmonella infection
B) Mycobacterium tuberculosis
C) Clostridium difficile
D) Pneumocystis pneumonia

Question 12

A patients current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide based on the patients medication regimen?

A) Avoid high-fat meals while taking this medication.
B) Limit fluid intake to 2 liters a day.
C) Limit sodium intake to 2 grams per day.
D) Take this medication without regard to meals.

Question 13

A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis?

A) Acute Abdominal Pain
B) Diarrhea
C) Bowel Incontinence
D) Constipation

Question 14

A patient 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 patients are usually discouraged from using them.
B) Researchers have not looked at the benefits of alternative therapy for patients with HIV, so we suggest that you stay away from these therapies until there is solid research data available.
C) Many patients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks.
D) Youll need to meet with your doctor to choose between an alternative approach to treatment and a medical approach.

Question 15

A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse should expect the primary care provider to order what test to confirm the EIA test results?

A) Another EIA test
B) Viral load test
C) Western blot test
D) CD4/CD8 ratio

Question 16

The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk?

A) Providing thorough oral care before and after meals
B) Administering prophylactic antibiotics
C) Promoting nutrition and adequate fluid intake
D) Applying skin emollients as needed

Question 17

A patient 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 ordered.
B) Encourage the patient to eat three balanced meals and a snack at bedtime.
C) Increase the patients oral fluid intake.
D) Encourage the patient to increase his or her activity level.

Question 18

A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response?

A) Do you think that you might already have HIV?
B) Dont worry. Your immune system is likely very healthy.
C) AIDS isnt transmitted by casual contact.
D) You cant contract AIDS in a hospital setting.

Question 19

A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?

A) Utilize a pressure-reducing mattress.
B) Limit the patients physical activity.
C) Apply antibiotic ointment to dependent skin surfaces.
D) Avoid contact with synthetic fabrics.

Question 20

A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?

A) The nurse wears face protection, gloves, and a gown when irrigating a wound.
B) The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves.
C) The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
D) The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.

Question 21

An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurses best response?

A) There is no way to know that for certain, but we do know that your baby has a one in four chance of being born with HIV.
B) Your physician is likely the best one to ask that question.
C) If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to worry about it now.
D) Its possible that your baby could contract HIV, either before, during, or after delivery.

Question 22

A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurses choice of educational interventions?

A) Many older adults do not see themselves as being at risk for HIV infection.
B) Many older adults are not aware of the difference between HIV and AIDS.
C) Older adults tend to have more sex partners than younger adults.
D) Older adults have the highest incidence of intravenous drug use.

Question 23

A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurses best response?

A) Theres no way to be sure you wont get HIV except to use condoms correctly.
B) Only the correct use of a female condom protects against the transmission of HIV.
C) There are new ways of protecting yourself from HIV that are being discovered every day.
D) Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV.

Question 24

A patient is in the primary infection stage of HIV. What is true of this patients current health status?

A) The patients HIV antibodies are successfully, but temporarily, killing the virus.
B) The patient is infected with HIV but lacks HIV-specific antibodies.
C) The patients risk for opportunistic infections is at its peak.
D) The patient may or may not develop long-standing HIV infection.

Question 25

A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following?

A) Static stage
B) Latent stage
C) Viral set point
D) Window period

Question 26

A patient 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

Question 27

A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?

A) Promoting appropriate use of complementary therapies
B) Addressing possible barriers to adherence
C) Educating the patient about the pathophysiology of HIV
D) Teaching the patient about the need for follow-up blood work

Question 28

The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action?

A) Assess the patient for additional signs and symptoms of Kaposis sarcoma.
B) Review the patients most recent viral load and CD4+ count.
C) Place the patient on respiratory isolation and inform the physician.
D) Perform oral suctioning to reduce the patients risk for aspiration.

Question 29

A patient has come into contact with HIV. As a result, HIV glycoproteins have fused w CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle?

A) Integration
B) Attachment
C) Cleavage
D) Budding

Question 30

An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL, and the nurse recognizes the patients increased risk for Mycobacterium aviumcomplex (MAC disease). The nurse should anticipate the administration of what drug?

A) Azithromycin
B) Vancomycin
C) Levofloxacin
D) Fluconazole

Question 31

A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea?

A) Zithromax
B) Sandostatin
C) Levaquin
D) Biaxin

Question 32

A patient 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 AIDS patients by increasing body fat stores?

A) Advera
B) Momordicacharantia
C) Megestrol
D) Ranitidine

Question 33

A nurse is completing a nutritional status of a patient 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

Question 34

A nurse is assessing the skin integrity of a patient 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

Question 35

A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next?

A) Flush the wound site with chlorhexidine.
B) Report to the emergency department or employee health department.
C) Apply a hydrocolloid dressing to the wound site.
D) Follow up with the nurses primary care provider.

Question 36

The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?

A) Maximize the patients fluid intake.
B) Provide total parenteral nutrition (TPN).
C) Keep the patients bed linens free of wrinkles.
D) Provide the patient with snug clothing at all times.

Question 37

A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?

A) Position the patient in the high Fowlers position whenever possible.
B) Temporarily eliminate animal protein from the patients diet.
C) Make sure the patient eats at least two servings of raw fruit each day.
D) Obtain a stool culture to identify possible pathogens.

Question 38

A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?

A) Teach the patient guided imagery.
B) Give the patient more control of her antiretroviral regimen.
C) Increase the patients activity level.
D) Collaborate with the patients physician to obtain an order for hydromorphone.

Question 39

A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?

A) Risk for Disuse Syndrome Related to Kaposis Sarcoma
B)Impaired Skin Integrity Related to Kaposis Sarcoma
C) Diarrhea Related to Kaposis Sarcoma
D) Impaired Swallowing Related to Kaposis Sarcoma

Question 40

A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.

A) Current medication regimen
B) Identification of patients support system
C) Immune system function
D) Genetic risk factors for HIV
E) History of sexual practices