Nokea
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.
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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 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 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.
A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the treatment of perinatal HIV transmission? (Select all that apply.)
- A. Client drinking water.
- B. Cultural beliefs about illness.
- C. Lack of antiviral medications.
- D. Lack of water.
- E. Unknown transmission routes.
Correct Answer: A,B,C,D
Rationale: Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to use formula. Cultural beliefs about illness, lack of available medications, and lack of water are possible barriers. Perinatal transmission is well known to occur across the placenta, during birth, from exposure to blood and body fluids during birth, and through breast-feeding.
A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that the goals for this client problem have been met?
- A. Chooses high-protein food.
- B. Has decreased oral discomfort.
- C. Eats 90% of meals and snacks.
- D. Has a weight gain of 2 pounds in 1 month.
Correct Answer: D
Rationale: The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.