Nokea
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.
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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 patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patients CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle?
- A. Integration
- B. Attachment
- C. Cleavage
- D. Budding
Correct Answer: B
Rationale: During the process of attachment, glycoproteins of HIV bind with the hosts uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life cycle.
A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurses best response?
- A. Theres no way to be sure you wont get HIV except to use condoms correctly.
- B. Only the correct use of a female condom protects against the transmission of HIV.
- C. There are new ways of protecting yourself from HIV that are being discovered every day.
- D. Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV.
Correct Answer: D
Rationale: Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual transmission of HIV infection. Both female and male condoms confer significant protection. New prevention techniques are not commonly discovered, though advances in treatment are constant.
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
- A. Maximize the patients fluid intake.
- B. Provide total parenteral nutrition (TPN).
- C. Keep the patients bed linens free of wrinkles.
- D. Provide the patient with snug clothing at all times.
Correct Answer: C
Rationale: Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Fluid intake should be adequate, and must be monitored, but maximizing fluid intake is not a goal. TPN is a nutritional intervention of last resort.
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action?
- A. Assess the patient for additional signs and symptoms of Kaposis sarcoma.
- B. Review the patients most recent viral load and CD4+ count.
- C. Place the patient on respiratory isolation and inform the physician.
- D. Perform oral suctioning to reduce the patients risk for aspiration.
Correct Answer: C
Rationale: These signs and symptoms are suggestive of tuberculosis, not Kaposis sarcoma; prompt assessment and treatment is necessary. There is no indication of a need for oral suctioning and the patients blood work will not reflect the onset of this opportunistic infection.