Nokea
The nurse is preparing to start an IV for a client who is combative. What precautionary measure should the nurse take in order to avoid a needlestick?
- A. Have the client placed in restraints.
- B. Ask for assistance.
- C. Refuse to start the IV.
- D. Give the client a sedative prior to starting the IV.
Correct Answer: B
Rationale: If a client is uncooperative, the nurse should request assistance when starting IV therapy. Restraints can cause the client to become more agitated and less cooperative. Sedation can be considered chemical restraint and can have side effects that are undesirable. Refusing to start the IV will not allow the client to receive the care required.
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The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluid(s) does the nurse inform them will transmit the virus? Select all that apply.
- A. Semen
- B. Urine
- C. Breast milk
- D. Blood
- E. Vaginal secretions
Correct Answer: A,C,D,E
Rationale: There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.
A woman infected with HIV comes into the clinic. What symptoms may be the focus of a medical complaint in women infected with HIV?
- A. Rashes on the face, trunk, palms, and soles
- B. Muscle and joint pain
- C. Gynecologic problems
- D. Weight loss
Correct Answer: C
Rationale: In women with HIV, gynecologic problems, such as abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may be the focus of a majority of complaints. Acute retroviral syndrome (viremia) may be the chief complaint in one third to more than one half of those infected, not necessarily women. Its manifestations include rashes, muscle and joint pain, and weight loss.
A female client comes to the clinic and tells the nurse, 'I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often.' Which nursing action is the priority for this client?
- A. Recommend abstinence or safer-sex practices.
- B. Offer information on human immunodeficiency virus (HIV) testing.
- C. Provide a prescribed topical antifungal agent to treat the client's vaginal infection.
- D. Refer the client to a support group with others experiencing the same symptoms.
Correct Answer: B
Rationale: In women, gynecologic problems may be the focus of the chief complaint for clients who are HIV positive but not yet diagnosed. Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may also correlate with HIV infection. Based on this information, the priority nursing action is to offer information on HIV testing to the client. Although recommending abstinence or safer-sex practices, providing a prescribed topical antifungal agent to treat the client's vaginal infection, and referring to a support group may be appropriate, the priority is to determine the source of the client's symptoms.
A client on antiretroviral drug therapy informs the nurse about sometimes forgetting to take the medication for a few days. What should the nurse inform the client can occur when the medications are not taken as prescribed?
- A. The funding for the medications will cease if the client is not taking the meds correctly.
- B. The client is risking the development of drug resistance and drug failure.
- C. The client will have to take the drugs intravenously to ensure compliance.
- D. The client will have to take higher doses of the antiviral medications.
Correct Answer: B
Rationale: Clients who neglect to take antiretroviral drugs as prescribed risk development of drug resistance. When drug levels are not adequately maintained, viral replication and mutations increase. Funding will not cease for noncompliance. The medications are not all available in IV form. Taking a higher dose of the medication if missed does not resolve drug resistance.
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform what?
- A. p24 antigen test for confirmation of diagnosis.
- B. Western blot test for confirmation of diagnosis.
- C. polymerase chain reaction test for confirmation of diagnosis.
- D. T4-cell count for confirmation of diagnosis.
Correct Answer: B
Rationale: The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.