Nokea
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
- A. Promoting appropriate use of complementary therapies
- B. Addressing possible barriers to adherence
- C. Educating the patient about the pathophysiology of HIV
- D. Teaching the patient about the need for follow-up blood work
Correct Answer: B
Rationale: ART is highly dependent on adherence to treatment, and the nurse should proactively address this. Blood work is necessary, but this will not have a direct bearing on the success or failure of treatment. Complementary therapies are appropriate, but are not the main factor in successful treatment. The patient may or may not benefit from teaching about HIV pathophysiology.
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An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL, and the nurse recognizes the patients increased risk for Mycobacterium avium complex (MAC disease). The nurse should anticipate the administration of what drug?
- A. Azithromycin
- B. Vancomycin
- C. Levofloxacin
- D. Fluconazole
Correct Answer: A
Rationale: HIV-infected adults and adolescents should receive chemoprophylaxis against disseminated Mycobacterium avium complex (MAC disease) if they have a CD4+ count less than 50 cells/L. Azithromycin (Zithromax) or clarithromycin (Biaxin) are the preferred prophylactic agents. Vancomycin, levofloxacin, and fluconazole are not prophylactic agents for MAC.
A patient is in the primary infection stage of HIV. What is true of this patients current health status?
- A. The patients HIV antibodies are successfully, but temporarily, killing the virus.
- B. The patient is infected with HIV but lacks HIV-specific antibodies.
- C. The patients risk for opportunistic infections is at its peak.
- D. The patient may or may not develop long-standing HIV infection.
Correct Answer: B
Rationale: The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus is not being eradicated and infection is certain. Opportunistic infections emerge much later in the course of the disease.
A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following?
- A. Static stage
- B. Latent stage
- C. Viral set point
- D. Window period
Correct Answer: C
Rationale: The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time a person infected with HIV tests negative even though he or she is infected.
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
- A. Perianal region and oral mucosa
- B. Sacral region and lower abdomen
- C. Scalp and skin over the scapulae
- D. Axillae and upper thorax
Correct Answer: A
Rationale: The nurse should inspect all the patients skin surfaces and mucous membranes, but the oral mucosa and perianal region are particularly vulnerable to skin breakdown and fungal infection.
A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test?
- A. Arrange for a portable x-ray machine to be used.
- B. Have the patient wear a mask to the x-ray department.
- C. Ensure that the radiology department has been disinfected prior to the test.
- D. Send the patient to the x-ray department, and have the staff in the department wear masks.
Correct Answer: A
Rationale: A patient who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the patients room. This confers more protection than disinfecting the radiology department or using masks.