Nokea
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.
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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.
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 human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?
- A. Consult with the pharmacy about drug interactions.
- B. Ensure the client understands the new medications.
- C. Give the new drugs without considering the old ones.
- D. Schedule all medications at standard times.
Correct Answer: A
Rationale: The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of disease.
A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first?
- A. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3.
- B. Client with selective immunoglobulin A deficiency and fever.
- C. Client with HIV and recent weight loss of 5 pounds.
- D. Client with AIDS and new-onset confusion.
Correct Answer: D
Rationale: A new-onset confusion in a client with AIDS could indicate a serious opportunistic infection or neurological complication, such as HIV encephalopathy or toxoplasmosis. This requires immediate assessment to determine the cause and initiate treatment. The other clients' conditions, while important, are less immediately life-threatening.
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.