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A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply oral anesthetic gels before meals.
- B. Assist with oral care.
- C. Offer the client frequent sips of cool drinks.
- D. Provide the client with alcohol-based mouthwash.
- E. Remind the client to use only a soft toothbrush.
Correct Answer: B,C,E
Rationale: The UAP can assist with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.
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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.
The nurse is caring for a client diagnosed with human immune deficiency virus. The client's CD4+ cell count is 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first?
- A. Initiate Droplet Precautions for the client.
- B. Notify the provider about the CD4+ results.
- C. Place the client under Airborne Precautions.
- D. Use Standard Precautions to provide care.
Correct Answer: C
Rationale: Since this client's CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next, the nurse notifies the provider about the low CD4+ count and requests alternative testing for TB. Standard Precautions are not adequate in this case.
A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?
- A. Ask the client about travel to any foreign countries.
- B. Assess the client about adherence to the drug regimen.
- C. Determine if the client has any new sexual partners.
- D. Gather more information about new living quarters or pets.
Correct Answer: B
Rationale: Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this client's viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.
A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the treatment of perinatal HIV transmission? (Select all that apply.)
- A. Client drinking water.
- B. Cultural beliefs about illness.
- C. Lack of antiviral medications.
- D. Lack of water.
- E. Unknown transmission routes.
Correct Answer: A,B,C,D
Rationale: Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to use formula. Cultural beliefs about illness, lack of available medications, and lack of water are possible barriers. Perinatal transmission is well known to occur across the placenta, during birth, from exposure to blood and body fluids during birth, and through breast-feeding.
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.