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A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?
- A. Assessing the client's lungs.
- B. Assessing mucous membranes.
- C. Assessing bowel sounds.
- D. Performing a neurological examination.
Correct Answer: B
Rationale: 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 client's mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.
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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 client's sexual activity and patterns.
- B. Encourage the client to maintain regular check-ups.
- C. Remind the client about safer sex practices.
- D. Tell the client to be retested in 2 months.
Correct Answer: A
Rationale: The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to developing antibodies to HIV. This period of time is known as the window period and can last up to 2 months. The nurse needs to assess the client's sexual behavior further to determine the proper response. Discussing safer sex practices is always appropriate, but assessing sexual activity is the priority to determine the risk of a false negative.
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 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 client's fluid and electrolyte status.
- B. Assisting the client to use a soft toothbrush.
- C. Obtaining a bedside commode if the client is weak.
- D. Providing gentle perineal cleansing after stools.
- E. Reporting any abnormal patient status.
Correct Answer: B,C,D,E
Rationale: The UAP can assist the client with getting out of bed, obtain a bedside commode for the client's use, cleanse the client's perineal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.
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.