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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.
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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.
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 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.
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.