Nokea
The nurse is caring for a patient who has just been diagnosed with early persistent HIV infection. Which of the following prophylactic measures should the nurse anticipate being included in the plan of care?
- A. Hepatitis B vaccine
- B. Pneumococcal vaccine
- C. Influenza virus vaccine
- D. Trimethoprim-sulfamethoxazole
- E. Varicella-zoster immune globulin
Correct Answer: A,B,C
Rationale: Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease, when the CD4 count has dropped or when infection has occurred.
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Which of the following patients will the nurse working in an HIV testing and treatment clinic anticipate teaching about antiretroviral therapy (ART)?
- A. A patient who is currently HIV negative but has unprotected sex with multiple partners
- B. A patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/?µL.
- C. An HIV-positive patient with a CD4+ count of 120/?µL who drinks a fifth of whiskey daily
- D. A patient who tested positive for HIV 2 years ago and has cytomegalovirus (CMV) disease
Correct Answer: D
Rationale: CMV disease is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4 count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4 count.
When assessing an individual who has been diagnosed with early persistent HIV infection and has a normal CD4 count, which of the following assessments should the nurse conduct?
- A. Check neurological orientation.
- B. Ask about problems with diarrhea.
- C. Palpate the regional lymph nodes.
- D. Examine the oral mucosa for lesions.
Correct Answer: C
Rationale: Persistent generalized lymphadenopathy is common in the early stage of persistent infection. Diarrhea, oral lesions, and neurological abnormalities would occur in the later stages of HIV infection.
After having a positive rapid-antibody test for HIV, a patient is anxious and does not appear to hear what the nurse is saying. Which of the following actions should the nurse implement?
- A. Teach the patient about the medications available for treatment.
- B. Inform the patient how to protect sexual and needle-sharing partners.
- C. Remind the patient about the need to return for retesting to verify the results.
- D. Ask the patient to notify individuals who have had risky contact with the patient.
Correct Answer: C
Rationale: After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.
The nurse is caring for a patient whose HIV status is unknown. Which of these patient exposures is most likely to require postexposure prophylaxis for the nurse?
- A. Needle stick with a needle and syringe used to draw blood
- B. Splash into the eyes when emptying a bedpan containing stool
- C. Contamination of open skin lesions with patient vaginal secretions
- D. Needle stick injury with a suture needle during a surgical procedure
Correct Answer: A
Rationale: Puncture wounds are the most common means for workplace transmission of bloodborne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.
The nurse is caring for a patient with HIV infection who has developed Mycobacterium avium complex infection. Which of the following goals is most appropriate for this patient?
- A. Be free from injury.
- B. Receive immunizations on time.
- C. Ensure adequate oxygenation.
- D. Maintain intact perineal skin.
Correct Answer: D
Rationale: The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection.