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A client with acquired immune deficiency syndrome has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client's partner is listed as the emergency contact, but the client's 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, as 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.
Correct Answer: A
Rationale: 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, so assuming the mother is the legal contact is not appropriate.
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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.
Which statements are true about human immune deficiency virus (HIV)? (Select all that apply.)
- A. In HIV, CD4+ cells begin to create new HIV particles.
- B. Antibodies the client produces are incomplete and do not interact with macrophages.
- C. Macrophages also 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.
Correct Answer: A,B,C,D
Rationale: In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not interact with macrophages. 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.
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 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.
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.