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A client is prescribed entecavir, which is supplied as a buffered powder. The nurse instructs the client to mix the powder with which of the following?
- A. Fruit juice
- B. Applesauce
- C. Water
- D. Gelatin
- E. Milk
Correct Answer: C
Rationale: The client should be instructed to mix the buffered powder with 4 ounces of water (not juice), stir until it is dissolved, and then drink it immediately. Using any other substance such as fruit juice, applesauce, gelatin, or milk would be inappropriate.
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A nurse is preparing a teaching plan for a client who is receiving antiviral therapy. Which of the following would the nurse include? Select all that apply.
- A. Only notify your physician if an allergic reaction to the antiviral drug occurs.
- B. These drugs are not a cure for the viral infection, but they will shorten the course of disease.
- C. Mark a calendar to designate the days the drug is to be taken so that you can keep to the ordered alternate-dosage schedule.
- D. These drugs will help in preventing the spread of the infection to those around you.
- E. Take precautions when you're outside because you might experience a sunburn reaction.
Correct Answer: B,C,E
Rationale: The nurse's teaching plan for antiviral drugs should include educating the client and family that antiviral drugs are not a cure for viral infection but will shorten the course of disease; that antiviral drugs will not prevent the spread of disease to others; that some antiviral drugs cause photosensitivity, so precaution should be taken when going outdoors; that a calendar should be marked to designate the days the drug is to be taken for clients on an alternate-dosage schedule; and that the physician should be notified if burning, stinging, itching, or rash worsens or becomes pronounced.
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.
A patient for whom antiretroviral therapy has been prescribed informs the nurse that she is taking oral contraceptives. The nurse responds that the combination of oral contraceptives and antiretroviral therapy can lead to which of the following?
- A. Decreased effectiveness of antiviral therapy.
- B. Increased risk of vaginal bleeding
- C. Decreased effectiveness of birth control pills
- D. Increased serum level of the antiretroviral
- E. Increased risk of infection
Correct Answer: C
Rationale: Antiretrovirals decrease the effectiveness of oral birth control agents. Combining antiretrovirals with birth control pills does not, however, increase the risk of vaginal bleeding, increase serum levels of the antiretroviral, decrease the effectiveness of antiviral therapy, or increase the risk of infection.
A client is receiving antiretroviral therapy. Which adverse reactions would the nurse include in the teaching plan for this client? Select all that apply.
- A. Altered taste
- B. Peripheral numbness
- C. Oral candidiasis
- D. Rash
- E. Fever
Correct Answer: A,B,D,E
Rationale: Adverse reactions associated with antiretroviral drugs are nausea, vomiting, diarrhea, altered taste, headache, fever, chills, rash, and numbness and tingling in the circumoral area or peripherally or both. Oral candidiasis is not associated with antiretroviral therapy.
Which of the following would the nurse identify as a goal for a client who is receiving an antiviral drug? Select all that apply.
- A. Adverse reactions are identified and treated.
- B. Adequate nutritional status is maintained.
- C. Perceptions of body changes are managed successfully.
- D. Skin integrity is successfully maintained.
- E. Therapeutic response is achieved.
Correct Answer: A,B,C,D,E
Rationale: The goals for a client taking antiviral drugs can include the following: adverse reactions are identified and treated, adequate nutritional status is maintained, perceptions of body changes are managed successfully, skin integrity is successfully maintained, and therapeutic response is achieved.