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A patient with skin lesions due to a viral infection has been prescribed a topical antiviral agent. When teaching the patient about this therapy, which of the following would the nurse emphasize?
- A. The drug will not prevent the spread of the disease to others.
- B. Topical drugs should be applied using the hand, not a finger cot or gloves.
- C. All lesions should be left open and not covered in any way.
- D. Sexual contact when lesions are present is permissible if barrier methods are used.
- E. Apply the drug twice daily for best results
Correct Answer: A
Rationale: The nurse should inform the patient that application of the drug does not prevent the spread of the disease to others. Topical drugs should be applied with a finger cot or gloves but not with bare hands. The nurse should instruct the patient to cover all lesions and not leave them open. The nurse should also stress the importance of avoiding sexual contact when lesions are present irrespective of contraceptive measures. The frequency of application depends on the specific drug prescribed.
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After teaching a group of nursing students about antiretroviral drugs, the instructor determines that the teaching was successful when the students identify that these drugs are used to treat which infections? Select all that apply.
- A. Hepatitis C virus (HCV)
- B. Human immunodeficiency virus (HIV)
- C. Acquired immunodeficiency syndrome (AIDS)
- D. Herpes simplex virus (HSV) 1
- E. Herpes simplex virus (HSV) 2
Correct Answer: B,C
Rationale: Antiretroviral drugs are used to treat HIV and AIDS.
A client diagnosed with HIV infection is receiving HAART. The client, who is alert and oriented, complains of anorexia, nausea, and vomiting. He has lost 10 pounds in the last 6 weeks. Additional assessment reveals pale, pink skin without any irritation or breakdown. He denies any complaints of pain. Which nursing diagnosis would the nurse identify as the priority for this client?
- A. Risk for Injury
- B. Risk for Imbalanced Nutrition: Less Than Body Requirements
- C. Risk for Impaired Skin Integrity
- D. Acute Pain
- E. Ineffective Coping
Correct Answer: B
Rationale: The client's complaints along with his weight loss strongly suggest a nursing diagnosis of Risk for Imbalanced Nutrition: Less Than Body Requirements as a priority. The client is alert and oriented, so his risk for injury is significantly low. There is no evidence of impaired skin integrity at present. However, this may become a concern if the client begins toæ??æ³? experience skin breakdown secondary to his poor nutritional status. The client denies any pain, so Acute Pain would be inappropriate. Ineffective Coping is not supported by the provided assessment data.
The nurse is preparing a plan of care for a client being treated with an antiviral drug. Which outcome would the nurse most likely identify? Select all that apply.
- A. Client remains free of other medical conditions.
- B. Client demonstrates an optimal response to therapy.
- C. Client exhibits continual changes in vital signs.
- D. Client demonstrates ability to manage adverse reactions.
- E. Client verbalizes understanding of the therapeutic regimen.
Correct Answer: B,D,E
Rationale: Optimal response to therapy and meeting of client needs related to the management of adverse reactions and an understanding of the therapeutic regimen are outcomes that should be addressed by the nurse in the planning step of the nursing process. Continually changing vital signs would be inappropriate. Remaining free of other medical conditions would be unrealistic.
The nurse is preparing to administer an antiviral drug to a client. Which of the following would the nurse include in the preadministration assessment? Select all that apply.
- A. Client's general state of health
- B. Blood glucose levels
- C. Resistance to infection
- D. Electrocardiogram findings
- E. Vital signs
Correct Answer: A,C,E
Rationale: The nurse's preadministration assessment of the client prior to administration of antiviral drugs should include determination of the client's general state of health and resistance to infection, record of client's symptoms and complaints, and record of vital signs. Blood glucose levels and electrocardiogram findings are not needed.
Clients receiving antiretroviral drugs for HIV infection may continue to contract opportunistic infections. The nurse would be alert for which of the following when assessing the client during therapy? Select all that apply.
- A. Fever.
- B. Malaise
- C. Sore throat
- D. Lethargy
- E. Hypotension
Correct Answer: A,B,C,D
Rationale: The nurse's ongoing assessment of HIV-positive clients should include close monitoring for signs of infection such as fever, malaise, sore throat, or lethargy.