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A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states, 'Whew! I was really worried about that result.' What action by the nurse is most important?
- A. Assess the client's sexual activity and patterns.
- B. Encourage the client to maintain regular check-ups.
- C. Remind the client about safer sex practices.
- D. Tell the client to be retested in 2 months.
Correct Answer: A
Rationale: The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to developing antibodies to HIV. This period of time is known as the window period and can last up to 2 months. The nurse needs to assess the client's sexual behavior further to determine the proper response. Discussing safer sex practices is always appropriate, but assessing sexual activity is the priority to determine the risk of a false negative.
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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 nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears staff members talking about the 'AIDS guy' and wondering how the client contracted the disease. What action by the nurse is best?
- A. Confront the staff members about unethical behavior.
- B. Ignore the behavior to avoid confrontation.
- C. Report the behavior to the unit's nursing management.
- D. Tell the client that other staff members are talking about him or her.
Correct Answer: A
Rationale: The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.
Which statements are true about human immune deficiency virus (HIV)? (Select all that apply.)
- A. In HIV, CD4+ cells begin to create new HIV particles.
- B. Antibodies the client produces are incomplete and do not interact with macrophages.
- C. Macrophages also stop functioning properly.
- D. Opportunistic infections and cancer are leading causes of death.
- E. People with stage 1 HIV disease are not infectious to others.
Correct Answer: A,B,C,D
Rationale: In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not interact with macrophages. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.
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 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.