Nokea
A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What action by the nurse is best?
- A. Assess the client for support systems.
- B. Determine if a clergy member would help.
- C. Provide detailed information about HIV treatment.
- D. Offer to tell the family for the client.
Correct Answer: A
Rationale: 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. Providing detailed information may be overwhelming at this stage, and the client may not want the family to know.
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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 client's 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 client's abdomen.
Correct Answer: A,C,D
Rationale: Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client's 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.
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 client's oxygen during activity.
- D. Pace activities, allowing for adequate rest.
Correct Answer: D
Rationale: 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 client's activity.
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 human immune deficiency virus.
- C. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV).
- D. Presence of HIV wasting syndrome.
- E. Taking antiretroviral medications.
Correct Answer: A,B,D
Rationale: A human with HIV/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 or HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi 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. Ensuring proper disposal of soiled dressings.
Correct Answer: D
Rationale: All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital to prevent the spread of infection.
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.
Correct Answer: B
Rationale: Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.