Chapter 19: Care of Patients with HIV Disease and Other Immune Deficiencies Nursing School Test Banks

Chapter 19: Care of Patients with HIV Disease and Other Immune Deficiencies
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

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?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
ANS: A
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. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.

DIF: Applying/Application REF: 328
KEY: HIV/AIDS| safer sex| immune disorders
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

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?
a. Anal intercourse
b. Masturbation
c. Oral sex
d. Vaginal intercourse
ANS: A
Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.

DIF: Understanding/Comprehension REF: 330
KEY: HIV/AIDS| safer sex| infection| immune disorders
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

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?
a. Consistent use of Standard Precautions
b. Double-gloving before body fluid exposure
c. Labeling charts and armbands HIV+
d. Wearing a mask within 3 feet of the client
ANS: A
According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.

DIF: Remembering/Knowledge REF: 332
KEY: HIV/AIDS| infection control| Standard Precautions| immune disorders
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

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?
a. Initiate Droplet Precautions for the client.
b. Notify the provider about the CD4+ results.
c. Place the client under Airborne Precautions.
d. Use Standard Precautions to provide care.
ANS: C
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. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

DIF: Applying/Application REF: 334
KEY: HIV/AIDS| Transmission-Based Precautions| infection control| immune disorders
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

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?
a. Assess the clients sexual activity and patterns.
b. Express happiness over the test result.
c. Remind the client about safer sex practices.
d. Tell the client to be retested in 3 months.
ANS: A
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. The other actions are not the most important, but discussing safer sex practices is always appropriate.

DIF: Applying/Application REF: 336
KEY: HIV/AIDS| safer sexual practices| nursing assessment| immune disorders
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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?
a. Ask the client about travel to any foreign countries.
b. Assess the client for adherence to the drug regimen.
c. Determine if the client has any new sexual partners.
d. Request information about new living quarters or pets.
ANS: B
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. After this, the other assessments may or may not be needed.

DIF: Applying/Application REF: 338
KEY: HIV/AIDS| nursing assessment| immune disorders| medications
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

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?
a. Administer sleeping medication.
b. Perform most activities for the client.
c. Increase the clients oxygen during activity.
d. Pace activities, allowing for adequate rest.
ANS: D
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. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the clients activity.

DIF: Applying/Application REF: 340
KEY: HIV/AIDS| immune disorders| rest and sleep| fatigue
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

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?
a. Chooses high-protein food
b. Has decreased oral discomfort
c. Eats 90% of meals and snacks
d. Has a weight gain of 2 pounds/1 month
ANS: D
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 nutrients.

DIF: Evaluating/Synthesis REF: 341
KEY: HIV/AIDS| malnutrition| nutrition
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

9. A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?
a. Adhering to Standard Precautions
b. Assessing tolerance to dressing changes
c. Performing hand hygiene before and after care
d. Disposing of soiled dressings properly
ANS: D
All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.

DIF: Applying/Application REF: 342
KEY: HIV/AIDS| wound care| dressings| infection control
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

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?
a. Infusions will be scheduled every 3 to 4 weeks.
b. Treatment is aimed at treating specific infections.
c. Unfortunately, there is no effective treatment.
d. You will need many immunoglobulin A infusions.
ANS: B
Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.

DIF: Understanding/Comprehension REF: 345
KEY: Immune disorders| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

11. An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?
a. Initiate Contact Precautions.
b. Place the client on Airborne Precautions.
c. Place the client on Droplet Precautions.
d. Use Standard Precautions consistently.
ANS: D
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.

DIF: Applying/Application REF: 334
KEY: HIV/AIDS| infection control| Standard Precautions
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

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?
a. Assess the client for support systems.
b. Determine if a clergy member would help.
c. Explain legal requirements to tell sex partners.
d. Offer to tell the family for the client.
ANS: A
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. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.

DIF: Applying/Application REF: 343
KEY: HIV/AIDS| nursing assessment| psychosocial response| support| caring
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

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?
a. Confront the staff members about unethical behavior.
b. Ignore the behavior; they will stop on their own soon.
c. Report the behavior to the units nursing management.
d. Tell the client that other staff members are talking about him or her.
ANS: A
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. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.

DIF: Applying/Application REF: 344
KEY: HIV/AIDS| communication| advocacy| caring| patient-centered care
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

14. A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. 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?
a. Contact the social worker to assist the client with advance directives.
b. Ignore the mother; the client does not want her to be involved.
c. Let the client know, gently, that nurses cannot be involved in these disputes.
d. Tell the client that, legally, the mother is the emergency contact.
ANS: A
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. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.

DIF: Applying/Application REF: 336
KEY: HIV/AIDS| autonomy| advocacy| referrals| LGBTQ
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

15. A client with human immune deficiency virus infection 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?
a. Consult with the pharmacy about drug interactions.
b. Ensure that the client understands the new medications.
c. Give the new drugs without considering the old ones.
d. Schedule all medications at standard times.
ANS: A
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. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.

DIF: Applying/Application REF: 339
KEY: HIV/AIDS| immune disorder| antiretrovirals| HAART
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

16. A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?
a. Auscultating the lungs
b. Assessing mucous membranes
c. Listening to bowel sounds
d. Performing a neurologic examination
ANS: B
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. The nurse will perform the other assessments as part of a comprehensive assessment.

DIF: Applying/Application REF: 334
KEY: HIV/AIDS| nursing assessment| fluids and electrolytes
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

17. A client with HIV/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?
a. Gabapentin can be used as an antidepressant too.
b. I have no idea why you should be taking this drug.
c. This drug helps treat the pain from nerve irritation.
d. You are at risk for seizures due to fungal infections.
ANS: C
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.

DIF: Understanding/Comprehension REF: 341
KEY: HIV/AIDS| neuropathic pain| tricyclic antidepressants| pain| pharmacologic pain management MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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?
a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C)
b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching
c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion
d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
ANS: A
A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

DIF: Applying/Application REF: 338
KEY: HIV/AIDS| immune disorders| prioritizing| fever| infection| white blood cell count
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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?
a. Truvada does not reduce the need for safe sex practices.
b. This drug has been taken off the market due to increases in cancer.
c. Truvada reduces the number of HIV tests you will need.
d. This drug is only used for postexposure prophylaxis.
ANS: A
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. This drug has not been taken off the market and is not used for postexposure prophylaxis.

DIF: Understanding/Comprehension REF: 332
KEY: HIV/AIDS| immune disorders| vaccinations| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

MULTIPLE RESPONSE

1. A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.)
a. CD4+ cells begin to create new HIV virus particles.
b. Antibodies produced are incomplete and do not function well.
c. Macrophages stop functioning properly.
d. Opportunistic infections and cancer are leading causes of death.
e. People with stage 1 HIV disease are not infectious to others.
ANS: A, B, C, D
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.

DIF: Remembering/Knowledge REF: 327
KEY: HIV/AIDS| immune disorders| inflammation
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. Which findings are AIDS-defining characteristics? (Select all that apply.)
a. CD4+ cell count less than 200/mm3 or less than 14%
b. Infection with Pneumocystis jiroveci
c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV)
d. Presence of HIV wasting syndrome
e. Taking antiretroviral medications
ANS: A, B, D
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 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

DIF: Remembering/Knowledge REF: 328
KEY: HIV/AIDS| immune disorders MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. 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? (Select all that apply.)
a. Clean drinking water
b. Cultural beliefs about illness
c. Lack of antiviral medication
d. Social stigma
e. Unknown transmission routes
ANS: A, B, C, D
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.

DIF: Analyzing/Analysis REF: 332
KEY: HIV/AIDS| infection control| culture| patient-centered care
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Psychosocial Integrity

4. A client with acquired immune deficiency syndrome (AIDS) 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? (Select all that apply.)
a. Aspartate transaminase, alanine transaminase: elevated
b. CD4+ cell count: 180/mm3
c. Creatinine: 1.0 mg/dL
d. Platelet count: 80,000/mm3
e. Serum sodium: 120 mEq/L
ANS: A, D, E
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. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal.

DIF: Analyzing/Analysis REF: 340
KEY: HIV/AIDS| laboratory values| antibiotics| immune disorders
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

5. A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Apply oral anesthetic gels before meals.
b. Assist the client with oral care every 2 hours.
c. Offer the client frequent sips of cool drinks.
d. Provide the client with alcohol-based mouthwash.
e. Remind the client to use only a soft toothbrush.
ANS: B, C, E
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.

DIF: Applying/Application REF: 341
KEY: HIV/AIDS| delegation| unlicensed assistive personnel (UAP)| oral care
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

6. A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assessing the clients fluid and electrolyte status
b. Assisting the client to get out of bed to prevent falls
c. Obtaining a bedside commode if the client is weak
d. Providing gentle perianal cleansing after stools
e. Reporting any perianal abnormalities
ANS: B, C, D, E
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. The nurse assesses fluid and electrolyte status.

DIF: Applying/Application REF: 341
KEY: HIV/AIDS| delegation| hygiene| elimination| patient safety| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

7. 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? (Select all that apply.)
a. Assess the clients mouth and throat.
b. Determine if the client has a stiff neck.
c. Ensure that the consent form is on the chart.
d. Maintain NPO status as prescribed.
e. Percuss the clients abdomen.
ANS: A, C, D
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. A stiff neck and abdominal percussion are not related to this diagnostic procedure.

DIF: Applying/Application REF: 334
KEY: HIV/AIDS| nursing assessment| informed consent| NPO| endoscopy
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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