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The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?
- A. Would you like me to have the chaplain come speak with you?
- B. Youll learn much about the promise of a cure for HIV.
- C. Can you tell me what concerns you most about dying?
- D. You need to maintain hope because you may live for several years.
Correct Answer: C
Rationale: The nurse can help the patient verbalize feelings and identify resources for support. The nurse should respond with an open-ended question to help the patient to identify fears about being diagnosed with a life-threatening chronic illness. Immediate deferral to spiritual care is not a substitute for engaging with the patient. The nurse should attempt to foster hope, but not in a way that downplays the patients expressed fears.
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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 with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education?
- A. Appropriate use of prophylactic antibiotics
- B. Importance of personal hygiene
- C. Signs and symptoms of wasting syndrome
- D. Strategies for adjusting antiretroviral dosages
Correct Answer: B
Rationale: Infection control is of high importance in patients living with HIV, thus personal hygiene is paramount. This is a more important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be independently adjusted. Prophylactic antibiotics are not normally prescribed unless the patients CD4 count is below 50.
A nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
- A. Ineffective Airway Clearance
- B. Impaired Oral Mucous Membranes
- C. Imbalanced Nutrition: Less than Body Requirements
- D. Activity Intolerance
Correct Answer: A
Rationale: Although all these nursing diagnoses are appropriate for a patient with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the patient with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns.
A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold?
- A. 75 cells/mm^3 of blood
- B. 200 cells/mm^3 of blood
- C. 325 cells/mm^3 of blood
- D. 450 cells/mm^3 of blood
Correct Answer: B
Rationale: When CD4+ T-cell levels drop below 200 cells/mm^3 of blood, the person is said to have AIDS.
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
- A. The nurse wears face protection, gloves, and a gown when irrigating a wound.
- B. The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves.
- C. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
- D. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.
Correct Answer: C
Rationale: Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when working with the same patient. Each of the other listed actions adheres to standard precautions.