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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.
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A patient who has diagnosed with AIDS tells the nurse, 'I have lots of thoughts about dying. Do you think I am just being morbid?' Which of the following responses by the nurse is most appropriate?
- A. Thinking about dying will not improve the course of AIDS.
- B. It is important to focus on the good things about your life now.
- C. Do you think that taking an antidepressant might be helpful to you?
- D. Can you tell me more about the kind of thoughts that you are having?
Correct Answer: D
Rationale: More assessment of the patient's psychosocial status is needed before taking any other action. The statements, 'Thinking about dying will not improve the course of AIDS' and 'It is important to focus on the good things in life' discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patient's feelings.
The nurse is caring for a pregnant patient who has recently been diagnosed with HIV. The patient asks the nurse, 'How soon after delivery of my baby can ART treatment be started?' Which of the following provide the basis for the nurse's response?
- A. It can be initiated while you are pregnant.
- B. It will start as soon as your baby is born.
- C. It depends upon whether you are breastfeeding your baby or not.
- D. It cannot begin until 7 days postpartum.
Correct Answer: A
Rationale: Women infected with HIV should receive optimal ART immediately, regardless of whether or not they are pregnant.
The nurse is caring for a patient with HIV who has a CD4+ cell count of 400/?µL. Which of the following factors is most important to consider when determining whether antiretroviral therapy (ART) will be initiated for this patient?
- A. Patient social support system
- B. HIV genotype and phenotype
- C. Potential medication adverse effects
- D. Patient ability to comply with ART schedule
Correct Answer: D
Rationale: Drug resistance develops quickly unless the patient takes ART medications on a stringent schedule, and this endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.
Which information about an HIV-positive patient who is taking antiretroviral medications is most important for the nurse to address when planning care?
- A. The patient's blood glucose level is 6.9 mmol/L.
- B. The patient complains of feeling 'constantly tired.'
- C. The patient is unable to state the adverse effects of the medications.
- D. The patient states 'sometimes I miss a dose of zidovudine (AZT).'
Correct Answer: D
Rationale: Since missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common adverse effects of ART. The nurse should discuss medication adverse effects with the patient, but this is not as important as addressing the skipped doses of AZT.
Which of the following nursing actions will be most useful in assisting a young adult college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
- A. Give the patient detailed information about possible medication adverse effects.
- B. Remind the patient of the importance of taking the medications as scheduled.
- C. Encourage the patient to join a support group for students who are HIV positive.
- D. Check the patient's class schedule to help decide when the ART should be taken.
Correct Answer: D
Rationale: The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.