Nokea
A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.
- A. Current medication regimen
- B. Identification of patients support system
- C. Immune system function
- D. Genetic risk factors for HIV
- E. History of sexual practices
Correct Answer: A,B,C,E
Rationale: Nursing assessment includes numerous focuses, including identification of medication use, support system, immune function and sexual history. HIV does not have a genetic component.
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A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patients CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle?
- A. Integration
- B. Attachment
- C. Cleavage
- D. Budding
Correct Answer: B
Rationale: During the process of attachment, glycoproteins of HIV bind with the hosts uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle.
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurses choice of educational interventions?
- A. Many older adults do not see themselves as being at risk for HIV infection.
- B. Many older adults are not aware of the difference between HIV and AIDS.
- C. Older adults tend to have more sex partners than younger adults.
- D. Older adults have the highest incidence of intravenous drug use.
Correct Answer: A
Rationale: It is known that many older adults do not see themselves as being at risk for HIV infection. Knowledge of the relationship between HIV infection and AIDS is not known to affect the incidence of new cases. The statements about sex partners and IV drug use are untrue.
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 nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response?
- A. Do you think that you might already have HIV?
- B. Dont worry. Your immune system is likely very healthy.
- C. AIDS isnt transmitted by casual contact.
- D. You cant contract AIDS in a hospital setting.
Correct Answer: C
Rationale: AIDS is commonly transmitted by contact with blood and body fluids. Patients, family, and friends must be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV infection.
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.