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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.
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A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Assess the client's mouth and throat.
- B. Determine if the client has a stiff neck.
- C. Ensure that the consent form is on the chart.
- D. Maintain NPO status as prescribed.
- E. Percuss the client's abdomen.
Correct Answer: A,C,D
Rationale: Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client's mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.
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 (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.)
- A. Opportunistic infections and cancer are leading causes of death.
- B. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV).
- C. Taking antiretroviral medications.
- D. Elevated liver enzymes.
- E. Serum sodium: 120 mEq/L.
Correct Answer: A,D,E
Rationale: The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes and low serum sodium should all be reported. Opportunistic infections and cancer are not laboratory values, and a positive ELISA test and antiretroviral medications are expected in this context.
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.
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.