Nokea
A nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
- A. Ineffective Airway Clearance
- B. Impaired Oral Mucous Membranes
- C. Imbalanced Nutrition: Less than Body Requirements
- D. Activity Intolerance
Correct Answer: A
Rationale: Although all these nursing diagnoses are appropriate for a patient with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the patient with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns.
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A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea?
- A. Zithromax
- B. Sandostatin
- C. Levaquin
- D. Biaxin
Correct Answer: B
Rationale: Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to be effective in managing chronic severe diarrhea. Zithromax, Levaquin, and Biaxin are not used to treat chronic severe diarrhea.
A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the patient. What action should the nurse take next?
- A. Flush the wound site with chlorhexidine.
- B. Report to the emergency department or employee health department.
- C. Apply a hydrocolloid dressing to the wound site.
- D. Follow up with the nurses primary care provider.
Correct Answer: B
Rationale: After initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility. Flushing is recommended, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended. Following up with the nurses own primary care provider would require an unacceptable delay.
A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what?
- A. The patient is immune to HIV.
- B. The patients immune system is intact.
- C. The patient has AIDS-related complications.
- D. The patient has been infected with HIV.
Correct Answer: D
Rationale: Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications.
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 with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote significant weight gain in AIDS patients by increasing body fat stores?
- A. Advera
- B. Momordica charantia
- C. Megestrol
- D. Ranitidine
Correct Answer: C
Rationale: Megestrol acetate (Megace), a synthetic oral progesterone preparation, promotes significant weight gain. In patients with HIV infection, it increases body weight primarily by increasing body fat stores. Advera is a nutritional supplement that has been developed specifically for people with HIV infection and AIDS. Momordica charantia (bitter melon) is given as an enema and is part of alternative treatment for HIV/AIDS. Ranitidine prevents ulcers.