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The nurse is caring for a client diagnosed with human immune deficiency virus. The client's CD4+ cell count is 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first?
- A. Initiate Droplet Precautions for the client.
- B. Notify the provider about the CD4+ results.
- C. Place the client under Airborne Precautions.
- D. Use Standard Precautions to provide care.
Correct Answer: C
Rationale: Since this client's CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next, the nurse notifies the provider about the low CD4+ count and requests alternative testing for TB. Standard Precautions are not adequate in this case.
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A client with acquired immune deficiency syndrome has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best?
- A. Contact the social worker to assist the client with advance directives.
- B. Ignore the mother, as the client does not want her to be involved.
- C. Let the client know, gently, that nurses cannot be involved in these disputes.
- D. Tell the client that legally, the mother is the emergency contact.
Correct Answer: A
Rationale: The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state, so assuming the mother is the legal contact is not appropriate.
A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Assess the client's mouth and throat.
- B. Determine if the client has a stiff neck.
- C. Ensure that the consent form is on the chart.
- D. Maintain NPO status as prescribed.
- E. Percuss the client's abdomen.
Correct Answer: A,C,D
Rationale: Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client's mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.
A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What action by the nurse is best?
- A. Assess the client for support systems.
- B. Determine if a clergy member would help.
- C. Provide detailed information about HIV treatment.
- D. Offer to tell the family for the client.
Correct Answer: A
Rationale: This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Providing detailed information may be overwhelming at this stage, and the client may not want the family to know.
A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply oral anesthetic gels before meals.
- B. Assist with oral care.
- C. Offer the client frequent sips of cool drinks.
- D. Provide the client with alcohol-based mouthwash.
- E. Remind the client to use only a soft toothbrush.
Correct Answer: B,C,E
Rationale: The UAP can assist with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states, 'Whew! I was really worried about that result.' What action by the nurse is most important?
- A. Assess the client's sexual activity and patterns.
- B. Encourage the client to maintain regular check-ups.
- C. Remind the client about safer sex practices.
- D. Tell the client to be retested in 2 months.
Correct Answer: A
Rationale: The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to developing antibodies to HIV. This period of time is known as the window period and can last up to 2 months. The nurse needs to assess the client's sexual behavior further to determine the proper response. Discussing safer sex practices is always appropriate, but assessing sexual activity is the priority to determine the risk of a false negative.