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A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis?
- A. Acute Abdominal Pain
- B. Diarrhea
- C. Bowel Incontinence
- D. Constipation
Correct Answer: B
Rationale: Diarrhea is a problem in 50% to 60% of all AIDS patients. As such, this nursing diagnosis is more likely than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply.
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A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
- A. Utilize a pressure-reducing mattress.
- B. Limit the patients physical activity.
- C. Apply antibiotic ointment to dependent skin surfaces.
- D. Avoid contact with synthetic fabrics.
Correct Answer: A
Rationale: Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Activity should be promoted, not limited, and contact with synthetic fabrics does not necessarily threaten skin integrity. Antibiotic ointments are not normally used unless there is a break in the skin surface.
A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?
- A. Teach the patient guided imagery.
- B. Give the patient more control of her antiretroviral regimen.
- C. Increase the patients activity level.
- D. Collaborate with the patients physician to obtain an order for hydromorphone.
Correct Answer: A
Rationale: Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue. Increased activity may be of benefit, but for other patients this may exacerbate feelings of anxiety or loss. Granting the patient control has the potential to reduce anxiety, but the patient is not normally given unilateral control of the ART regimen. Hydromorphone is not used to treat anxiety.
A patient with HIV infection has developed severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
- A. Administer antidiarrheal medications on a scheduled basis, as ordered.
- B. Encourage the patient to eat three balanced meals and a snack at bedtime.
- C. Increase the patients oral fluid intake.
- D. Encourage the patient to increase his or her activity level.
Correct Answer: A
Rationale: Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis, provided the patients diarrhea is not caused by an infectious microorganism. Increased oral fluid may exacerbate diarrhea; IV fluid replacement is often indicated. Small, more frequent meals may be beneficial, and it is unrealistic to increase activity while the patient has frequent diarrhea.
An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurses best response?
- A. There is no way to know that for certain, but we do know that your baby has a one in four chance of being born with HIV.
- B. Your physician is likely the best one to ask that question.
- C. If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to worry about it now.
- D. Its possible that your baby could contract HIV, either before, during, or after delivery.
Correct Answer: D
Rationale: Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breast-feeding. There is no evidence that the infants risk is 25%. Deferral to the physician is not a substitute for responding appropriately to the patients concern. Downplaying the patients concerns is inappropriate.
A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurses best response?
- A. Theres no way to be sure you wont get HIV except to use condoms correctly.
- B. Only the correct use of a female condom protects against the transmission of HIV.
- C. There are new ways of protecting yourself from HIV that are being discovered every day.
- D. Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV.
Correct Answer: D
Rationale: Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual transmission of HIV infection. Both female and male condoms confer significant protection. New prevention techniques are not commonly discovered, though advances in treatment are constant.