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A client is ordered to receive an antiretroviral agent that is categorized as a nonnucleoside reverse transcriptase inhibitor. Which of the following would the nurse expect to administer?
- A. Indinavir
- B. Nevirapine
- C. Saquinavir
- D. Ritonavir
- E. Zidovudine
Correct Answer: B
Rationale: Nevirapine is classified as a nonnucleoside reverse transcriptase inhibitor. Indinavir, saquinavir, and ritonavir are classified as protease inhibitors. Zidovudine is a nucleoside reverse transcriptase inhibitor.
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The nurse is preparing to administer an antiviral drug to a client. Which of the following would the nurse include in the preadministration assessment? Select all that apply.
- A. Client's general state of health
- B. Blood glucose levels
- C. Resistance to infection
- D. Electrocardiogram findings
- E. Vital signs
Correct Answer: A,C,E
Rationale: The nurse's preadministration assessment of the client prior to administration of antiviral drugs should include determination of the client's general state of health and resistance to infection, record of client's symptoms and complaints, and record of vital signs. Blood glucose levels and electrocardiogram findings are not needed.
After teaching a group of nursing students about antiretroviral drugs, the instructor determines that the teaching was successful when the students identify that these drugs are used to treat which infections? Select all that apply.
- A. Hepatitis C virus (HCV)
- B. Human immunodeficiency virus (HIV)
- C. Acquired immunodeficiency syndrome (AIDS)
- D. Herpes simplex virus (HSV) 1
- E. Herpes simplex virus (HSV) 2
Correct Answer: B,C
Rationale: Antiretroviral drugs are used to treat HIV and AIDS.
Clients receiving antiretroviral drugs for HIV infection may continue to contract opportunistic infections. The nurse would be alert for which of the following when assessing the client during therapy? Select all that apply.
- A. Fever.
- B. Malaise
- C. Sore throat
- D. Lethargy
- E. Hypotension
Correct Answer: A,B,C,D
Rationale: The nurse's ongoing assessment of HIV-positive clients should include close monitoring for signs of infection such as fever, malaise, sore throat, or lethargy.
A patient is being discharged from a health care facility but is required to continue antiviral therapy at home. Which of the following points should the nurse include in the teaching plan to educate the patient?
- A. A slight elevation in temperature is normal and needn't be reported.
- B. Double the dosage of the drug if you miss a dose.
- C. Stop taking the drug as soon as the symptoms of the infection disappear.
- D. Make sure to notify your primary health care provider if you develop any adverse reactions.
- E. Take the drug with food to reduce stomach upset
Correct Answer: D
Rationale: The nurse should instruct the patient to report adverse reactions to the primary health care provider. The nurse should also tell the patient to report any increase in temperature, even if it is a slight increase. If the patient misses a dose, the next dose should be taken as soon as remembered, but it should not be doubled. The nurse should also instruct the patient to take the drug exactly as directed for the full course of therapy, even if the symptoms of the infection disappear. Taking the drug with food is not a general requirement for all antivirals but may apply to specific drugs.
A client diagnosed with HIV infection is receiving HAART. The client, who is alert and oriented, complains of anorexia, nausea, and vomiting. He has lost 10 pounds in the last 6 weeks. Additional assessment reveals pale, pink skin without any irritation or breakdown. He denies any complaints of pain. Which nursing diagnosis would the nurse identify as the priority for this client?
- A. Risk for Injury
- B. Risk for Imbalanced Nutrition: Less Than Body Requirements
- C. Risk for Impaired Skin Integrity
- D. Acute Pain
- E. Ineffective Coping
Correct Answer: B
Rationale: The client's complaints along with his weight loss strongly suggest a nursing diagnosis of Risk for Imbalanced Nutrition: Less Than Body Requirements as a priority. The client is alert and oriented, so his risk for injury is significantly low. There is no evidence of impaired skin integrity at present. However, this may become a concern if the client begins toæ??æ³? experience skin breakdown secondary to his poor nutritional status. The client denies any pain, so Acute Pain would be inappropriate. Ineffective Coping is not supported by the provided assessment data.