Nokea
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.
You may also like to solve these questions
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 HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that the goals for this client problem have been met?
- A. Chooses high-protein food.
- B. Has decreased oral discomfort.
- C. Eats 90% of meals and snacks.
- D. Has a weight gain of 2 pounds in 1 month.
Correct Answer: D
Rationale: The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.
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 HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best?
- A. Gabapentin can be used as an antidepressant too.
- B. I have no idea why you should be taking this drug.
- C. This drug helps treat the pain from nerve irritation.
- D. You are at risk for seizures due to fungal infections.
Correct Answer: C
Rationale: Many classes of medications are used for neuropathic pain, including gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client, not admit ignorance.
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.