Nokea
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.
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The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
- A. Attach the condom prior to erection.
- B. A condom may be reused with the same partner if ejaculation has not occurred.
- C. Use skin lotion as a lubricant if alternatives are unavailable.
- D. Hold the condom by the cuff upon withdrawal.
Correct Answer: D
Rationale: The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, or cold cream should not be used with condoms because they cause latex deterioration/condom breakage. The condom should be held during withdrawal so it does not come off the penis. Condoms should never be reused.
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.
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.
A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication?
- A. HIV encephalopathy
- B. B-cell lymphoma
- C. Kaposis sarcoma
- D. Wasting syndrome
Correct Answer: A
Rationale: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations.
A patient who has AIDS is being treated for Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
- A. Risk for Disuse Syndrome Related to Kaposis Sarcoma
- B. Impaired Skin Integrity Related to Kaposis Sarcoma
- C. Diarrhea Related to Kaposis Sarcoma
- D. Impaired Swallowing Related to Kaposis Sarcoma
Correct Answer: B
Rationale: Kaposis sarcoma (KS) is a disease that involves the endothelial layer of blood and lymphatic vessels. This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk for disuse syndrome.