Medical-Surgical Nursing: Med Surg 2 Test 1 HIV Flashcards


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Lewis 7th Ed, Ignatavicius 7th ed ch 21,
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1

Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area?

a.Placing the scalpel in a needle safe container

b.Testing the patient and offering treatment to the nurse

c.Removing sterile gloves and disposing of in kick bucket

d.Providing a medical evaluation of the nurse to the manager

B

Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps in appropriate containers are always part of the perioperative process and are not the process for postexposure. A confidential medical evaluation is provided to the nurse, not the manager.

2

During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of a white, thick substance on the patient’s uncircumcised glans penis. What is the nurse’s next step?

a.Record this as a normal finding.

b.Avoid embarrassing questions about sexual activity.

c.Notify the provider about a suspected sexually transmitted infection.

d.Tell the patient to avoid doing self-examinations until symptoms clear.

A

A small amount of thick, white smegma sometimes collects under the foreskin in the uncircumcised male and is considered normal. Penile pain or swelling, genital lesions, and urethral discharge are signs and symptoms that may indicate sexually transmitted infections (STI). All men 15 years and older need to perform a male-genital self-examination monthly. The nurse needs to assess a patient’s sexual history and use of safe sex habits. Sexual history reveals risks for STI and HIV.

3

The nurse is caring for a patient who recently had unprotected sex with a partner who has HIV. Which response by the nurse is best?

a.“You should have your blood drawn today to see if you were infected.”

b.“If you have the virus, you will have flu-like symptoms in 6 months.”

c.“Highly active antiretroviral therapy has been shown effective in slowing the disease process.”

d.“I will set you up with a support group to help you cope with dying within the next 10 years.”

C

Highly active retroviral therapy increases the survival time of a person with HIV or AIDS. HIV antibodies will not show up in blood work for 6 weeks to 3 months. The infection stage of HIV lasts for about a month after the virus is contracted; during that time, the patient may experience flu-like symptoms. A support group may be beneficial for a patient who contracts HIV; however, it is unknown whether the patient has contracted HIV, and antiretroviral therapy has helped people live beyond the 10 years expected if HIV goes untreated.

DIF:Apply (application)REF:719

OBJ: Identify and describe nursing interventions to promote sexual health.

TOP: Communication and Documentation MSC: Physiological Adaptation

4

A mother brings her 12-year-old daughter into a clinic and inquires about getting a human papillomavirus (HPV) vaccine that day. Which information will the nurse share with the mother and daughter about the HPV vaccine?

a.Protects against human immunodeficiency virus (HIV)

b.Protects against cervical cancer

c.Protects against chlamydia

d.Protects against pregnancy

B

The HPV vaccine is effective against the four most common types of HPVs that can cause cervical cancer. It is not effective against HIV, chlamydia, or pregnancy.

DIF:Understand (comprehension)REF:719-720 | 728

OBJ: Discuss the nurse’s role in maintaining or enhancing a patient’s sexual health.

TOP: Teaching/Learning MSC: Health Promotion and Maintenance

5

Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area?

a.Placing the scalpel in a needle safe container

b.Testing the patient and offering treatment to the nurse

c.Removing sterile gloves and disposing of in kick bucket

d.Providing a medical evaluation of the nurse to the manager

: B

Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps in appropriate containers are always part of the perioperative process and are not the process for postexposure. A confidential medical evaluation is provided to the nurse, not the manager.

DIF:Apply (application)REF:470

OBJ:Explain the postexposure process.TOP:Implementation

MSC: Safety and Infection Control

6

A patient seen in the outpatient clinic has an immune deficiency involving the T-lymphocytes. The nurse should teach the patient about the need for more frequent screening for

  1. malignancy.
  2. allergies.
  3. autoimmune disorders.
  4. antibody deficiency.

A

Rationale: Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by humoral immunity.

Cognitive Level: Application Text Reference: p. 220

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

7

A patient who seeks health care for vague symptoms of fatigue and headaches has HIV testing and is found to have a positive enzyme immunoassay (EIA) for HIV antibodies. In discussing the test results with the patient, the nurse informs the patient that

  1. the enzyme immunoassay test will need to be repeated to verify the results.
  2. a viral culture will be done to determine the progress of the disease.
  3. it will probably be 10 or more years before the patient develops AIDS.
  4. the Western blot test will need to be done to determine whether AIDS has developed.

A

Rationale: After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not part of HIV testing. Because the nurse does not know how recently the patient was infected, it is not appropriate to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.

Cognitive Level: Application Text Reference: p. 256

Nursing Process: Implementation NCLEX: Physiological Integrity

8

Four years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and a low viral load. The nurse teaches the patient that

  1. the patient is at risk for development of opportunistic infections because of CD4+

cell destruction.

  1. the patient is in a clinical and biologic latent period, during which very few viruses are being replicated.
  2. anti-HIV antibodies produced by B cells enter CD4+ cells infected with HIV to stop replication of viruses in the cells.
  3. the body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity.

D

Rationale: The patient is the early chronic stage of infection, when the body is able to produce enough CD4+ cells to maintain the CD4+ count at a normal level. The risk for opportunistic infection is low because of the normal CD4+ count. Although the viral load in the blood is low, intracellular reproduction of virus still occurs. Anti-HIV antibodies produced by B cells attack the viruses in the blood, but not intracellular viruses.

Cognitive Level: Application Text Reference: pp. 252, 257

Nursing Process: Implementation NCLEX: Physiological Integrity

9

A patient who tested positive for HIV 3 years ago is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP). Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), the patient is diagnosed as having

  1. early chronic infection.
  2. HIV infection.
  3. AIDS.
  4. intermediate chronic infection.

C

Rationale: Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other responses indicate an earlier stage of HIV infection than is indicated by the PCP infection.

Cognitive Level: Comprehension Text Reference: p. 253

Nursing Process: Assessment NCLEX: Physiological Integrity

10

During posttest counseling for a patient who has positive testing for HIV, the patient is anxious and does not appear to hear what the nurse is saying. At this time, it is most important that the nurse

  1. inform the patient how to protect sexual and needle-sharing partners.
  2. teach the patient about the medications available for treatment.
  3. ask the patient to notify individuals who have had risky contact with the patient.
  4. remind the patient about the need to return for retesting to verify the results.

D

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.

Cognitive Level: Application Text Reference: pp. 256, 264

Nursing Process: Implementation NCLEX: Psychosocial Integrity

11

A patient who is diagnosed with AIDS and has developed Kaposi’s sarcoma tells the nurse, “I have lots of thoughts about dying. Do you think I am just being morbid?” Which response by the nurse is most appropriate?

  1. “Thinking about dying will not improve the course of AIDS.”
  2. “Although your diagnosis is serious, there are more treatments available now.”
  3. “Try to focus on the good things in life because stress impairs the immune system.”
  4. “Tell me what kind of thoughts you have about dying.”

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 “Try 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. The statement, “Although your diagnosis is serious, there are more treatments available now” is correct, but without further assessment, it is impossible to know whether this responds to the patient’s concerns.

Cognitive Level: Application Text Reference: pp. 260, 265, 267

Nursing Process: Implementation NCLEX: Psychosocial Integrity

12

A pregnant woman with a history of asymptomatic HIV infection is seen at the clinic. Which information will the nurse include when teaching the patient?

  1. Although infants of HIV-infected mothers always test positive for HIV antibodies, most infants are not infected with the virus.
  2. Because she has not developed AIDS, the infant will not contract HIV during intrauterine life.
  3. The infant will be started on zidovudine (AZT) after delivery to prevent HIV infection.
  4. It is likely that her newborn will develop HIV infection unless she takes antiretroviral drugs during the pregnancy.

A

Rationale: Because antibodies are transmitted from the mother to the fetus during intrauterine life, all infants of HIV-positive mothers will test positive at birth. Ongoing antibody (or viral) testing is needed to determine whether the infant is infected with HIV. Transmission of the virus can occur during fetal life even if the mother does not have AIDS. Infants of HIV-positive mothers are not routinely started on antiretroviral therapy (ART). Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy.

Cognitive Level: Application Text Reference: p. 250

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

13

Interventions such as promotion of nutrition, exercise, and stress reduction should be promoted by the nurse for patients who have HIV infection, primarily because these interventions will

  1. promote a feeling of well-being in the patient.
  2. prevent transmission of the virus to others.
  3. improve the patient’s immune function.
  4. increase the patient’s strength and self-care ability.

C

Rationale: The primary goal for the patient with HIV infection is to increase immune function, and these interventions will promote a healthy immune system. They may also promote a feeling of well-being and increase strength, but these are not the priority goals for HIV-positive patients. These activities will not prevent the risk for transmission to others because the patient will still be HIV positive.

Cognitive Level: Comprehension Text Reference: p. 265

Nursing Process: Planning NCLEX: Physiological Integrity

14

The occupational health nurse will teach the nursing staff that the highest risk of acquiring HIV from an HIV-infected patient is

  1. a needlestick with a suture needle during a surgical procedure.
  2. contamination of open skin lesions with vaginal secretions.
  3. a needlestick with a needle and syringe used to draw blood.
  4. splashing the eyes when emptying a bedpan containing stool.

C

Rationale: Puncture wounds are the most common means for workplace transmission of blood-borne 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.

Cognitive Level: Comprehension Text Reference: p. 250

Nursing Process: Assessment

NCLEX: Safe and Effective Care Environment

15

A patient has recently tested positive for HIV and asks the nurse about drug therapy for HIV infection. The nurse informs the patient that

  1. drug therapy for HIV is indicated only for patients whose CD4+ cell counts indicate that AIDS has developed.
  2. medication therapy is delayed as long as possible to prevent development of viral resistance to the drugs.
  3. treatment is individualized based on CD4+ counts, the amount of virus in the blood, and the patient’s wishes.
  4. ART is typically started soon after HIV diagnosis to prevent progression of the disease.

C

Rationale: ART is typically considered when the CD4+ count drops below normal levels or the viral load is high in patients who are appropriate for ART and desire ART. ART is used to prevent the progression to AIDS and is used in patients who have AIDS. ART is not delayed as long as possible but can be started when the CD4+ counts are relatively high in some patients. ART is not started soon after HIV diagnosis; rather, it is started when CD4+ count, viral load, or patient symptoms indicate that it will be beneficial.

Cognitive Level: Application Text Reference: pp. 256-257

Nursing Process: Implementation NCLEX: Physiological Integrity

16

Drug therapy is being considered for an HIV-infected patient who has a CD4+ cell count of 400/µl. The nursing assessment that is most important in determining whether therapy will be used is the patient’s

  1. social support system offered by significant others and family.
  2. socioeconomic status and availability of medical insurance.
  3. understanding of the multiple side effects that the drugs may cause.
  4. willingness and ability to comply with stringent medication schedules.

D

Rationale: Drug resistance develops quickly unless the patient takes multiple drugs 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.

Cognitive Level: Comprehension Text Reference: pp. 264-265

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

17

Which of these patients will the nurse working in an HIV testing and treatment clinic anticipate teaching about ART?

  1. A patient who is HIV negative but has unprotected sex with multiple partners
  2. A patient who has been HIV positive for 5 years and has cytomegalovirus (CMV) retinitis
  3. A patient who was infected with HIV 15 years ago and has a CD4 count of 740/µl
  4. An HIV-positive patient with a CD4 count of 120/µl who drinks a fifth of whiskey daily

: B

Rationale: CMV retinitis 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 require 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.

Cognitive Level: Application Text Reference: p. 253

Nursing Process: Planning NCLEX: Physiological Integrity

18

When teaching a patient with HIV infection about ART, the nurse explains that these drugs

  1. work in various ways to decrease viral replication in the blood.
  2. boost the ability of the immune system to destroy the virus.
  3. destroy intracellular virus as well as lowering the viral load.
  4. increase the number of CD4+ cells available to fight the HIV.

A

Rationale: The three groups of antiretroviral drugs work in different ways to decrease the ability of the virus to replicate. The drugs do not work by boosting the ability of the immune system or CD4 cells to fight the virus. The viral load detected in the blood is decreased with effective therapy, but intracellular virus is still present.

Cognitive Level: Application Text Reference: pp. 256-257

Nursing Process: Implementation NCLEX: Physiological Integrity

19

When assessing an individual who has been diagnosed with early chronic HIV infection and has a normal CD4+ count, the nurse will

  1. ask about problems with diarrhea.
  2. examine the oral mucosa for lesions.
  3. check neurologic orientation.
  4. palpate the regional lymph nodes.

D

Rationale: Persistent generalized lymphadenopathy is common in the early stage of chronic infection. Diarrhea, oral lesions, and gait abnormalities would occur in the later stages of HIV infection.

Cognitive Level: Application Text Reference: p. 252

Nursing Process: Assessment NCLEX: Physiological Integrity

20

While teaching community groups about AIDS, the nurse informs people that the most common method of transmission of the HIV virus currently is

  1. perinatal transmission to the fetus.
  2. sharing equipment to inject illegal drugs.
  3. transfusions with HIV-contaminated blood.
  4. sexual contact with an infected partner.

D

Rationale: Sexual contact with an infected partner is currently the most common mode of transmission, although HIV is also spread through perinatal transmission, through sharing drug injection equipment, and through transfusions with HIV-infected blood.

Cognitive Level: Comprehension Text Reference: p. 250

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

21

A 24-year-old woman who uses injectable illegal drugs asks the nurse about preventing AIDS. The nurse informs the patient that the best way to reduce the risk of HIV infection from drug use is to

  1. participate in a needle-exchange program.
  2. clean drug injection equipment before use.
  3. ask those who share equipment to be tested for HIV.
  4. avoid sexual intercourse when using injectable drugs.

A

Rationale: Participation in needle-exchange programs has been shown to control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced by individuals in withdrawal. HIV antibodies do not appear for several weeks to months after exposure, so testing drug uses would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

Cognitive Level: Comprehension Text Reference: pp. 262-263

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

22

At the health promotion level of care for HIV infection, which question is most appropriate for the nurse to ask?

  1. “Are you having any symptoms such as severe weight loss or confusion?”
  2. “Are you experiencing any side effects from the antiretroviral medications?
  3. “Do you need any assistance to obtain antiretroviral drugs or other treatments?”
  4. “Do you use any injectable drugs or have sexual activity with multiple partners?”

D

Rationale: At the health-promotion level, the nurse screens for behaviors that might increase the risk for HIV infection and implements interventions to prevent infection (or, in the case of an already infected patient, implement interventions to prevent progression of the disease to AIDS). The other questions would be appropriate at the acute intervention level, when the patient already has significant immune compromise.

Cognitive Level: Application Text Reference: pp. 260-261

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

23

A patient with HIV infection has developed Mycobacterium avium complex infection. An appropriate outcome for the patient is that the patient will

  1. be free from injury.
  2. maintain intact perineal skin.
  3. have adequate oxygenation.
  4. receive immunizations.

B

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.

Cognitive Level: Analysis Text Reference: p. 255

Nursing Process: Planning NCLEX: Physiological Integrity

24

A patient who has been treated for HIV infection for 7 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. The nurse will anticipate teaching the patient about

  1. treatment with antifungal agents.
  2. a change in antiretroviral therapy.
  3. foods that are higher in protein.
  4. the benefits of daily exercise.

B

Rationale: A frequent first intervention for metabolic disorders is a change in ART. Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

Cognitive Level: Application Text Reference: pp. 266-267

Nursing Process: Planning NCLEX: Physiological Integrity

25

The nurse is preparing to give the following medications to an HIV-positive patient who is hospitalized with PCP. Which is most important to administer at the right time?

  1. Nystatin (Mycostatin) tablet for vaginal candidiasis
  2. Aerosolized pentamadine (NebuPent) for PCP infection
  3. Oral acyclovir ((Zovirax to treat systemic herpes simplex
  4. Oral saquinavir (Inverase) to suppress HIV infection

: D

Rationale: It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

Cognitive Level: Application Text Reference: pp. 258, 264-265

Nursing Process: Implementation NCLEX: Physiological Integrity

26

To evaluate the effectiveness of ART, the nurse will schedule the patient for

  1. viral load testing.
  2. enzyme immunoassay.
  3. rapid HIV antibody testing.
  4. immunofluorescence assay.

A

Rationale: The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect for HIV antibodies, which remain positive even with effective ART.

Cognitive Level: Application Text Reference: p. 265

Nursing Process: Planning NCLEX: Physiological Integrity

27

When designing a program to decrease the incidence of HIV infection in the community, the nurse will prioritize education about

  1. how to prevent transmission between sexual partners.
  2. methods to prevent perinatal HIV transmission.
  3. ways to sterilize needles used by injectable drug users.
  4. means to prevent transmission through blood transfusions.

A

Rationale: Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide education about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

Cognitive Level: Application Text Reference: pp. 250, 260-263

Nursing Process: Planning NCLEX: Physiological Integrity

28

The nurse explains to the patient newly diagnosed with HIV that prophylactic measures that should be taken as early as possible during the course of the infection include which the following (Select all that apply.)?

  1. Hepatitis A vaccine
  2. Hepatitis B vaccine
  3. Pneumococcal vaccine
  4. Influenza virus vaccine
  5. Trimethoprim-sulfamethoxazole
  6. Varicella zoster immune globulin

A, B, C, D

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.

Cognitive Level: Application Text Reference: pp. 253-255

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

29

**New Book**

Ignatavicius Chapter 21

30

Which action by the nurse is most effective to prevent becoming exposed to the human immune deficiency virus (HIV)?

a.Always use Standard Precautions with all clients in the workplace.

b.Place clients who are HIV positive in Contact Precautions.

c.Wash hands before and after contact with clients who are HIV positive.

d.Convert parenteral medications to an oral form for clients who are HIV positive.

A

The best prevention for health care providers is the consistent use of Standard Precautions with all clients, as recommended by the Centers for Disease Control and Prevention (CDC). Contact Precautions are not indicated unless the client has an infection such as Clostridium difficile or MRSA (methicillin-resistant Staphylococcus aureus).

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

31

The nurse is caring for a young client who has acquired immune deficiency syndrome (AIDS) and a very low CD4+ cell count. The nurse is teaching the client how to avoid infection at home. Which statement by the client indicates that additional teaching is needed?

a.I will let my sister clean my pet iguanas cage from now on.

b.My brother will change the kitty litter box from now on.

c.It will seem funny but Ill run my toothbrush through the dishwasher.

d.I will not drink juice that has been sitting out for longer than an hour.

A

Immune compromised clients should avoid having reptiles or turtles as pets and should avoid changing cat litter to help prevent opportunistic infections. Drinking juice that has been at room temperature for longer than 1 hour can lead to opportunistic infection and should be avoided. Clients should clean their toothbrushes daily by running them in the dishwasher or rinsing them in liquid laundry bleach.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

32

The nurse is working with a client at a public health clinic. The client says to the nurse, The doctor said that my CD4+ count is 450. Is that good? What is the nurses best response?

a.Your count is high so you can cut back on your medication.

b.Your count is normal because your medications are working well.

c.Your count is a bit low and you are susceptible to infection.

d.Your count is very low and you actually now have AIDS.

C

A CD4+ T-cell count of 450 cells/mm3 of blood is low, and the client is at increased risk for developing an infection. Normal CD4+ counts range from 800 to 1000 cells/mm3. To be diagnosed with AIDS, a client must have a CD4+ T-cell count of <200 cells/mm3 (or a CD4+ T-cell percentage of <4%) and/or an opportunistic infection.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 360

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Teaching/Learning

33

The nurse is caring for a young woman at the primary health care clinic. Which assessment finding leads the nurse to question the client about risk factors for HIV?

a.Six vaginal yeast infections in the last 12 months

b.Unable to become pregnant for the last 2 years

c.Severe cramping and irregular periods

d.Very heavy periods and breakthrough bleeding

A

Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women. Decreased immune function allows overgrowth of this fungus. Infertility, heavy periods, and cramping are not generally indicative of HIV.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 361

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

34

A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first?

a.Assess the clients deep tendon reflexes.

b.Ask the client to place his chin on his chest.

c.Start an IV line with normal saline.

d.Assess the clients pupil reaction.

B

The clients symptoms are associated with cryptococcal meningitis, so the nurse should first ask the client to place the chin on his or her chest. The presence of nuchal rigidity (pain when flexing the chin to the chest) helps confirm the diagnosis. An IV line may be started after the neurologic assessment is completed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

35

The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis. Which is the best nursing intervention for this client?

a.Initiate respiratory isolation for the next 72 hours.

b.Initiate seizure precautions with padded siderails.

c.Thicken the clients liquids to honey consistency.

d.Administer IV pentamidine isethionate (Pentam).

B

Cryptococcosis is a debilitating form of meningitis that can cause seizures, so seizure precautions should be initiated. Respiratory isolation is not indicated. Dysphagia is not seen with cryptococcal meningitis, so thickened liquids are not indicated. Pentam is given for Pneumocystis jiroveci pneumonia (PJP).

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

36

A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The clients purified protein derivative (PPD) test, placed 3 days ago in the clinic, is negative. Which action by the nurse is most appropriate?

a.Place the client in Airborne Precautions.

b.Facilitate the clients chest x-ray.

c.Initiate a 3-day calorie count.

d.Start an IV of normal saline.

A

The clients symptoms are indicative of tuberculosis (TB). With AIDS, the clients CD4+ T-cell count is so low that the client cannot mount an immune response to the PPD; thus it appears negative. The client needs to be placed in Airborne Precautions until other diagnostic tests rule out TB. The other interventions are appropriate, but they do not take priority over infection control principles.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Analysis)

37

The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide (Fuzeon). Which precaution is important for the nurse to communicate to this client?

a.Stop taking the medication if you develop a fever.

b.Rotate the sites where you will be giving the injections.

c.Take this medication with a snack or a small meal.

d.Do not drive or operate machinery while taking this drug.

B

Fuzeon is available only as a subcutaneous injection and can cause injection site reactions and nodules. The client should be taught the subcutaneous technique, including rotation of sites. The client should not stop taking this medication for fever, it can be given without regard to food, and the drug will not make the client sleepy or drowsy, so caution with driving or operating machinery is not needed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Teaching/Learning

38

A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, The doctor said that my viral load is reduced. What does this mean? What is the nurses best response?

a.The HAART medications are working well right now.

b.You are not as contagious as you were anymore.

c.Your HIV infection is becoming resistant to your medications.

d.You are developing an opportunistic infection.

A

The fact that the amount of virus is reduced means that the HAART regimen is working well to suppress viral replication. The risk of becoming infected by an HIV-positive person is always present. The reduced viral load is not related to an opportunistic infection or to resistance to medication.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 370

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Communication and Documentation

39

The nurse is seeing clients at a drop-in primary health clinic. Which client does the nurse teach about the risks of acquiring HIV?

a.Middle-aged woman with a new sexual partner

b.Young male who has male sexual partners

c.All clients who come to the clinic

d.Young woman having her first gynecologic examination

C

All sexually active people should know their HIV status, and all people need to have education on their risk of acquiring HIV infection. Anyone who engages in sexual activity has some risk.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 362

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning

40

An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate?

a.Renal function studies

b.Liver enzymes

c.Blood glucose monitoring

d.Albumin and prealbumin

B

Kaletra can cause liver complications, and clients taking it should have liver function studies. The clients symptoms could indicate a liver problem. Renal function and blood glucose are not affected by Kaletra. The client may have an albumin and a prealbumin drawn if he or she has lost a great deal of weight and malnutrition is suspected, but the more common diagnostic test for a client taking Kaletra would be liver function studies.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

41

The nurse has been exposed to HIV through splashing of urine from a client who is HIV positive with a low viral load. The urine came into contact with the nurses face. Which drug regimen does the nurse prepare to initiate?

a.Retrovir (zidovudine) for 14 days

b.Retrovir (zidovudine) for 28 days

c.Retrovir (zidovudine) and Epivir (lamivudine) for14 days

d.Retrovir (zidovudine) and Epivir (lamivudine) for 28 days

D

The Centers for Disease Control and Prevention have developed guidelines for postexposure prophylaxis (PEP). This nurses exposure requires basic PEP with two drugs for 28 days.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Planning)

42

The nurse is teaching a client how to prevent transmitting HIV to his sexual partner. Which statement by the client indicates that additional teaching is needed?

a.I can throw the condoms in the trash after I have used them.

b.I will store my condoms in my wallet so they are always handy.

c.Water-based lubricants are best to prevent condom breakage.

d.The condom needs to stay on until I withdraw my penis.

B

Condoms should be stored in a cool, dry place. Wallets are not recommended because body heat can weaken the latex in the condom. The condom should stay on the penis until it is completely withdrawn. Condoms should be used only once and then discarded. Oil-based lubricants can weaken latex, possibly causing tearing or leakage, so only water-based lubricants are recommended.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)

MSC: Integrated Process: Teaching/Learning

43

The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a student indicates that additional teaching is required?

a.A woman can still get pregnant if she is HIV positive.

b.I wont get HIV if I only have oral sex with my partner.

c.Showering after intercourse will not prevent HIV transmission.

d.People with HIV are still contagious even if they take HAART drugs.

B

HIV may be transmitted via oral sex when mucous membranes or nonintact skin comes in contact with infected body fluids (semen or vaginal secretions) or blood. Women who are HIV positive may get pregnant, and showering after intercourse will not reduce the risk of HIV transmission. HAART will lower viral loads, but the client will still be able to transmit the HIV virus to others.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)

MSC: Integrated Process: Teaching/Learning

44

The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed?

a.I will wash my hands whenever I get home from work.

b.I will make sure to have my own tube of toothpaste at home.

c.I will run my toothbrush through the dishwasher every evening.

d.I will be sure to eat lots of fresh fruits and vegetables every day.

D

The client should avoid eating raw fruits, vegetables, and salads because of the risk of infection. Hands should be washed whenever returning home, and immune compromised clients should not share toothbrushes or toothpaste. Toothbrushes should be run through the dishwasher nightly.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

45

The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The client states, Im an old woman! I cannot possibly get HIV. What is the nurses best response?

a.Your vaginal walls become thicker after menopause, which increases your risk.

b.Women in your age-group are the fastest growing population of AIDS clients today.

c.Hormonal fluctuations after menopause make it harder to fight off infection.

d.You might be right. How often do you engage in sexual activities?

B

Women are the fastest growing group with HIV infection and AIDS. Infection with HIV can occur at any age, and postmenopausal women experience thinning of vaginal tissue along with an age-related (not hormonal) decline in immune function. This places the older woman at higher risk of acquiring HIV infection. The frequency of sexual activity is not as relevant as the sexual activities the person practices.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 361

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

46

A client has selective immune globulin A (IgA) deficiency. The provider orders an infusion of immune globulin (IVIG). Which action by the nurse is best?

a.Start a second IV line for the clients antibiotics.

b.Call the physician to clarify the order.

c.Review the clients renal panel before administration.

d.Obtain baseline vital signs and another set after 15 minutes.

B

Clients with selective IgA deficiency are not treated with IVIG because it contains very little IgA, and because the risk of allergic reactions is high. The nurse should contact the provider to clarify what medications the client will be taking.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

47

The nurse is working with a client who has AIDS-related dementia and will soon be discharged to the care of family members. What teaching topic is best for the nurse to include in the discharge plan?

a.Feed the client when he will not do it by himself.

b.Make sure that a clock and a calendar are easily visible.

c.Remove locks from bathroom and bedroom doors.

d.Do not allow the client to smoke when he is alone.

B

Having a clock and a calendar easily visible will help the client keep track of the date and time and will assist with reorientation. Banning smoking, removing locks, and feeding the client will not facilitate reorientation when the client is confused.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Behavioral Interventions)

MSC: Integrated Process: Teaching/Learning

48

A client with HIV who is taking highly active antiretroviral therapy (HAART) medications is in radiology waiting for a chest x-ray when medications are due. What action by the nurse is best?

a.Call radiology to see when the client will be brought back to the nursing unit.

b.Send the nursing assistant to radiology to bring the client back to the nursing unit.

c.Take the clients medications to radiology and administer them there if possible.

d.Stagger the next dose of the medication if the current dose is given late.

C

HAART medications must be given on time and in the correct dose when an HIV client is in the hospital. Missing or delaying even a few doses can lead to drug resistance. The best option would be for the nurse to administer the medications in radiology as the client continues to wait for the x-ray. Calling the radiology department might give the nurse information but does not ensure that the client receives the medication on time. Bringing the client back to the nursing unit might delay the x-ray.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

49

An HIV-positive client verbalizes concerns about the high cost of antiretroviral medications. What is the nurses best response?

a.The medications are actually less expensive than they used to be.

b.These medications are the best course of treatment for you.

c.You should be glad the medications will help prolong your life.

d.Lets talk to the social worker about getting financial assistance for you.

D

This response demonstrates the nurses role as client advocate by identifying resources to help meet the clients needs. The nurse should not belittle the clients concerns by telling the client to be glad the medications are working, or that they are less expensive than previously.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with the Interdisciplinary Team) MSC: Integrated Process: Caring

50

The nurse is caring for a client who is HIV positive. The client has become confused over the course of the shift, and the clients pupils are no longer reacting to light equally. The nurse anticipates an order for which medication?

a.Prednisone (Deltazone)

b.Trimethoprim/sulfamethoxazole (Bactrim)

c.Pentamidine isethionate (Pentam)

d.Ketoconazole (Nizoral)

A

Confusion and changes in pupillary assessment in an HIV-positive client indicate increased intracranial pressure (ICP). Increased ICP in these clients is managed with corticosteroids like prednisone. Bactrim is an antibiotic, Pentam is an antiprotozoal, and Nizoral is an antifungal medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis)

51

A client verbalizes a fear of contracting HIV because she has a history of intravenous substance abuse. What instructions does the nurse provide to the client to help minimize this risk?

a.Boil all needles and syringes for at least 20 minutes before using them again and be sure not to share them.

b.Rinse used needles and syringes with water followed by laundry bleach after using them.

c.Rinse used needles and syringes with rubbing alcohol before and after using them.

d.Run all needles and syringes through the dishwasher with an extra rinse cycle before using them again.

B

To minimize the risk for HIV transmission, needles should be cleaned with laundry bleach after use. Boiling needles and syringes and rinsing with alcohol are not recommended. Running needles and syringes through the dishwasher will not sanitize them sufficiently. The client should be encouraged not to share needles and syringes.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 362

TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)

MSC: Integrated Process: Teaching/Learning

52

The nursing supervisor is working with an HIV-positive nurse who has open weeping blisters on her arms after being exposed to poison ivy. Which instructions should the nursing supervisor provide to the nurse before she starts her shift?

a.You should reassure your clients that you are not contagious.

b.You should work phone triage at the desk today rather than taking clients.

c.You should wear a long-sleeved scrub jacket today while working with clients.

d.You should not care for clients who are immune compromised or in isolation.

B

HIV-positive health care workers should not perform direct client care when they have open sores.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Planning)

53

The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in confirming progression of the clients diagnosis to AIDS?

a.Generalized lymphadenopathy

b.HIV-positive status for 8 years

c.Low-grade fever for the last 10 days

d.Thick white patches on the clients tongue

D

Candidiasis, which presents with thick white patches on the tongue and oral mucosa, is associated with the development of AIDS after HIV infection. The fact that the client has been positive for 8 years or has a low-grade fever is not significant.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

54

A nursing assistant asks the nurse if respiratory isolation is needed for a client with Pneumocystis jiroveci pneumonia. What is the nurses best response?

a.This type of pneumonia is an opportunistic infection, so the staff is not at risk.

b.You should wear a mask and a gown to provide care.

c.Yes, please institute respiratory isolation because this is very contagious.

d.You are not at risk for this infection if you have had a vaccination.

A

Pneumocystis jiroveci pneumonia is an opportunistic infection that will not cause disease in staff with healthy immune systems. Standard Precautions should be used for this client. Contact, Airborne, or Droplet Precautions are not indicated for this client. Health care staff do not get vaccinated for this infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

55

When obtaining a sexual history from a client in a clinic setting, the nurse notes that the client appears very uncomfortable and pauses for long periods before answering the nurses questions. What is the nurses best response?

a.I am sorry that my questions are making you very uncomfortable.

b.Dont worry. Well be done with these questions in no time at all.

c.Take your time. I realize that this is a very private topic to talk about.

d.These questions are making you uncomfortable, so well finish next time.

C

The client should be given time to collect his or her thoughts and composure before answering questions. The nurse should not apologize for asking pertinent questions about the clients health history. The sexual history should not be deferred until the next appointment. Recognizing the difficulty the client may be experiencing is helpful in establishing a therapeutic relationship.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)

MSC: Integrated Process: Caring

56

The nurse asks a young adult client if she is sexually active. The client asks why the nurse needs to know. What is the nurses best response?

a.I just need to make sure that the information you are providing is reliable.

b.I have to fill in answers to all of the questions on the health history form.

c.If you are sexually active, we should talk about ways to prevent getting HIV.

d.I will have to notify your partner if you have a sexually transmitted disease.

C

The nurse should assess whether the client is sexually active to determine whether it is appropriate to teach about safer sex practices. The nurse would not notify the clients sexual partners if a sexually transmitted disease were diagnosed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Caring

57

The nurse is completing a health history for a client and begins to obtain a sexual history. What is the nurses best opening question?

a.How long have you been sexually active?

b.Are you in a monogamous relationship with your spouse?

c.How do you feel about answering questions about your sexual history?

d.Have you noticed any problems with your ability to have or enjoy sex?

C

The nurse should begin with an assessment of the clients comfort level with the topic. The nurse should not assume that the client is sexually active or start with questions about the clients spouse. The nurse also should not use words like monogamous, which frequently are misunderstood by the public. The question about sexual ability and enjoyment is a closed-ended question, and if the client answers no, it will be awkward for the nurse to continue discussing this topic.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)

MSC: Integrated Process: Caring

58

The nurse is caring for a client with HIV who has been prescribed didanosine (Videx EC). Which action by the nurse is most appropriate?

a.Help the client plan specific meal and dosing times.

b.Explain that the client will have frequent complete blood counts (CBCs) drawn.

c.Advise the client to take Videx EC with milk or a small meal.

d.Tell the client to take Tylenol (acetaminophen) for any abdominal pain.

A

Videx EC must be taken on an empty stomach 30 minutes before or 2 hours after a meal. The nurse should assist the client in planning a daily schedule that includes meals and drug doses. Videx does not affect bone marrow, so frequent CBCs are not needed. A client on this drug who reports abdominal pain should be assessed for pancreatitis, a common adverse effect.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

59

The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select all that apply.)

a.Use sterile gloves and gowns whenever the nursing staff is in contact with the client.

b.Provide an incentive spirometer to encourage coughing and deep breathing by the client.

c.Keep a blood pressure cuff, thermometer, and stethoscope in the clients room for his or her use only.

d.Use N95 respirators (all nursing staff) when in the clients room.

e.Request that the family take home the fresh flowers that are at the clients bedside.

f.Assist the client with meticulous oral care after meals and at bedtime.

B, C, E, F

The nursing staff should encourage coughing and deep breathing to prevent pneumonia, and incentive spirometry will be helpful. Assessment equipment such as thermometers and blood pressure cuffs should be kept in the room only for the use of this client, rather than being used by other clients on the unit as well. Fresh flowers can harbor microorganisms and should be removed from the room. Meticulous oral care will help to prevent infection by Candida.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

60

The nurse is to give a client ganciclovir (Cytovene) for cytomegalovirus (CMV) retinitis. The dosage is 5 mg/kg IV every 12 hours. The client weighs 185 pounds. How many milligrams of ganciclovir does the client receive per dose? mg/dose

420

185 lb 1 kg/2.2 lb 5 mg/kg = 420 mg/dose

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

61

The nurse is to give a client rifampin (Rifadin) for tuberculosis. The dosage is 10 mg/kg/day. The client weighs 198 lb, and the medication is available in 150-mg capsules. How many capsules of rifampin does the client receive daily? __________ capsules/day?

6

198 lb 1 kg/2.2 10 mg/kg = 900 mg 1 capsule/150 mg = 6 capsules/day

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

62

In order to fully assess the patient and plan appropriate care including health teaching regarding sexuality the nurse should realize that which patient is most at risk for sexual abuse?

a. A recently divorced 50-year-old woman

b. A Hispanic teenage girl

c. A 30-year-old African-American male

d. An individual with intellectual or developmental disabilities

ANS: D

As more of these individuals move into mainstream society, it is important that sexual health is promoted, including teaching regarding sexual norms. Otherwise these individuals are likely victims of unhealthy sexual practices or sexual abuse. In today's society, the newly unpartnered are likely to begin dating and acquire one or more new sexual partners. This group is at significant risk for exposure to sexually transmitted infections and requires health teaching related to safer sexual practices. The Hispanic teenage girl is at increased risk for unintended teen pregnancy. Adolescent pregnancy puts an undue burden on the young woman during a crucial period of growth and development. Hispanic teens experience double the rate of pregnancy of Caucasian adolescents. Major health disparities continue to exist between African-Americans and their Caucasian counterparts—in particular a significantly increased risk for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted diseases.

REF: Page 211 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

63

The school nurse is developing a curriculum for a junior human sexuality class. In order to provide the most up-to-date information, the nurse should be aware that which is the single most effective primary prevention strategy for preventing sexually transmitted diseases?

a.

A vaccine to prevent HPV infection

b.

HIV screening

c.

Education directed at high-risk behaviors

d.

The male condom

ANS: D

When used correctly, the male condom continues to be the single most effective method for preventing sexually transmitted diseases as well as being a very highly effective contraceptive agent. A significant primary prevention strategy is the recent introduction of a vaccine used to prevent cervical cancer and genital warts caused by HPV. One of two FDA-approved vaccines should be routinely administered to 11- and 12-year-old girls and can be given up to the age of 26. HIV screening is recommended for all sexually active teens by the Centers for Disease Control and Prevention. Screening for existing disease is a secondary prevention strategy. By educating teens towards behavior change related to high-risk behaviors, nurses may be able to reduce the risk for contracting sexually transmitted infections.

REF: Page 213 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

64

A 37-year-old heterosexual African-American man has come for his annual health screening. Which test must the nurse ensure is ordered for this patient?

a.

Human papilloma virus (HPV)

b.

Prostate-specific antigen (PSA)

c.

HIV

d.

Venereal disease research laboratory (VDRL)

ANS: B

PSA testing is recommended annually for men at increased risk for prostate cancer. This includes men with a family history or those of African-American descent. HPV testing would likely be ordered for patients with genital warts. This might not be necessary for this patient. Tests for HIV should be ordered for patients that belong to high-risk populations, including men who have sex with men, and all pregnant women. All sexually active men and women should have a VDRL and rapid plasma reagin performed.

REF: Page 213 OBJ: NCLEX® Client Needs Category: Physiological Integrity

65

In order to fully assess the patient and plan appropriate care including health teaching regarding sexuality the nurse should realize that which patient is most at risk for sexual abuse?

a.

A recently divorced 50-year-old woman

b.

A Hispanic teenage girl

c.

A 30-year-old African-American male

d.

An individual with intellectual or developmental disabilities

D

As more of these individuals move into mainstream society, it is important that sexual health is promoted, including teaching regarding sexual norms. Otherwise these individuals are likely victims of unhealthy sexual practices or sexual abuse. In today's society, the newly unpartnered are likely to begin dating and acquire one or more new sexual partners. This group is at significant risk for exposure to sexually transmitted infections and requires health teaching related to safer sexual practices. The Hispanic teenage girl is at increased risk for unintended teen pregnancy. Adolescent pregnancy puts an undue burden on the young woman during a crucial period of growth and development. Hispanic teens experience double the rate of pregnancy of Caucasian adolescents. Major health disparities continue to exist between African-Americans and their Caucasian counterparts—in particular a significantly increased risk for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted diseases.

REF: Page 211 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

66

NEW BOOK

Brunner & Seddarth 14th Edition

67

A nurse is working with a male patient who has recently received a diagnosis of human immunodeficiency virus (HIV). When performing patient education during discharge planning, what
goal should the nurse emphasize most strongly?
A) Encourage the patient to exercise within his limitations.
B) Encourage the patient to adhere to his therapeutic regimen.
C) Appraise the patients level of nutritional awareness.
D) Encourage a disease-free state,

Ans: B
Feedback:
One of the goals of patient education is to encourage people to adhere to their therapeutic regimen. This
is a very important goal because if patients do not adhere to their therapeutic regimen, they will not
attain their optimal level of wellness. In this patients circumstances, this is likely a priority over exercise
or nutrition, though these are important considerations. A disease-free state is not obtainable.

68

In your role as a community health nurse, you are focusing your current health promotion efforts on
diseases that are disproportionately represented among ethnic and racial minorities. Which of the
following diseases would you likely address? Select all that apply.
A) Human immunodeficiency virus (HIV)
B) Cancer
C) Heart disease
D) Chronic obstructive pulmonary disease (COPD)
E) Alzheimers disease

Ans: A, B, C
Feedback:
Ethnic and racial minorities are disproportionately burdened with cancer, heart disease, diabetes, human
immunodeficiency virus (HIV), infection/acquired immunodeficiency syndrome (AIDS), and other
conditions. COPD and Alzheimers disease are incorrect because health care disparities have not been
noted with these two diseases.
17.

69

After working with a patient who has human immunodeficiency (HIV) for several weeks, the nurse has
become more aware of the role of health disparities. Which of the following variables are known to
underlie health disparities? Select all that apply.
A) Poverty
B) Isolated geographic location
C) Overdependence on publicly funded facilities
D) Male gender
E) Allergy status

Ans: A, B, C
Feedback:
Many reasons are cited for these disparities, including low socioeconomic status, health behaviors,
limited access to health care because of poverty or disability, environmental factors, and direct and
indirect manifestations of discrimination. Other causes include lack of health insurance; overdependence
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 137
on publicly funded facilities; and barriers to health care, such as insufficient transportation, geographic
location (not enough providers in an area), cost of services, and the low numbers of minority health care
providers. Male gender and a patients allergy status are not identified as contributors to health
disparities.

70

Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is
highly reluctant to receive a transfusion, stating, Im terrified of getting AIDS from a blood transfusion.
How can the nurse best address the patients concerns?
A) All the donated blood in the United States is treated with antiretroviral medications before it is
used.
B) That did happen in some high-profile cases in the twentieth century, but it is no longer a
possibility.
C) HIV was eradicated from the US blood supply in the early 2000s.
D) The chances of contracting AIDS from a blood transfusion in the United States are exceedingly
low.

Ans: D
Feedback:
The patient can be reassured about the very low possibility of contracting HIV from the transfusion.
However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated
blood. The blood supply is constantly dynamic, due to the brief life of donated blood.

71

The results of a patients most recent blood work and physical assessment are suggestive of immune
thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following
potential causes? Select all that apply.
A) Hepatitis
B) Acute renal failure
C) HIV
D) Malignant melanoma
E) Cholecystitis

Ans: A, C
Feedback:
Viral illnesses have the potential to cause ITP. Renal failure, malignancies, and gall bladder
inflammation are not typical causes of ITP.

72

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends.
Members of what group currently have the greatest risk of contracting HIV?
A) Gay, bisexual, and other men who have sex with men
B) Recreational drug users
C) Blood transfusion recipients
D) Health care providers

Ans: A
Feedback:
Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and
account for 2% of the population but 61% of the new infections. This exceeds the incidence among drug
users, health care workers, and transfusion recipients.

73

A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has
ordered a chest radiograph. How should the nurse most safely facilitate the test?
A) Arrange for a portable x-ray machine to be used.
B) Have the patient wear a mask to the x-ray department.
C)
Ensure that the radiology department has been disinfected prior to the test.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 694
D) Send the patient to the x-ray department, and have the staff in the department wear masks.

Ans: A
Feedback:
A patient who is immunocompromised is at an increased risk of contracting nosocomial infections due
to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in
the patients room. This confers more protection than disinfecting the radiology department or using
masks.

74

A public health nurse is preparing an educational campaign to address a recent local increase in the
incidence of HIV infection. The nurse should prioritize which of the following interventions?
A) Lifestyle actions that improve immune function
B) Educational programs that focus on control and prevention
C) Appropriate use of standard precautions
D) Screening programs for youth and young adults

Ans: B
Feedback:
Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is
essential. Educational interventions are the primary means by which behaviors can be influenced.
Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV
infection. Ineffective use of standard precautions apply to very few cases of HIV infection.

75

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/mm3 of blood
B) 200 cells/mm3 of blood
C) 325 cells/mm3 of blood
D) 450 cells/mm3 of blood

Ans: B
Feedback:
When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS

76

A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the
patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing
diagnosis?
A) Acute Abdominal Pain
B) Diarrhea
C) Bowel Incontinence
D) Constipation

Ans: B
Feedback:
Diarrhea is a problem in 50% to 60% of all AIDS patients. As such, this nursing diagnosis is more likely
than abdominal pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to
apply.

77

A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and
complementary therapies. How should the nurse best respond?
A) Complementary therapies generally have not been approved, so patients are usually discouraged
from using them.
B) Researchers have not looked at the benefits of alternative therapy for patients with HIV, so we
suggest that you stay away from these therapies until there is solid research data available.
C) Many patients with HIV use some type of alternative therapy and, as with most health treatments,
there are benefits and risks.
D) Youll need to meet with your doctor to choose between an alternative approach to treatment and a
medical approach.

Ans: C
Feedback:
The nurse should approach the topic of alternative or complementary therapies from an open-ended,
supportive approach, emphasizing the need to communicate with care providers. Complementary
therapies and medical treatment are not mutually exclusive, though some contraindications exist.
Research supports the efficacy of some forms of complementary and alternative treatment.

78

patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse
should expect the primary care provider to order what test to confirm the EIA test results?
A) Another EIA test
B) Viral load test
C) Western blot test
D) CD4/CD8 ratio

Ans: C
Feedback:
The Western blot test detects antibodies to HIV and is used to confirm the EIA test results. The viral
load test measures HIV RNA in the plasma and is not used to confirm EIA test results, but instead to
track the progression of the disease process. The CD4/CD8 ratio test evaluates the ratio of CD4 and CD8
cells but is not used to confirm results of EIA testing.

79

The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin
Integrity Related to Candidiasis. What nursing intervention best addresses this risk?
A) Providing thorough oral care before and after meals
B) Administering prophylactic antibiotics
C) Promoting nutrition and adequate fluid intake
D) Applying skin emollients as needed

Ans: A
Feedback:
Thorough mouth care has the potential to prevent or limit the severity of this infection. Antibiotics are
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irrelevant because of the fungal etiology. The patient requires adequate food and fluids, but these do not
necessarily prevent candidiasis. Skin emollients are not appropriate because candidiasis is usually oral

80

A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate
nursing intervention to help alleviate the diarrhea?
A) Administer antidiarrheal medications on a scheduled basis, as ordered.
B) Encourage the patient to eat three balanced meals and a snack at bedtime.
C) Increase the patients oral fluid intake.
D) Encourage the patient to increase his or her activity level.

Ans: A
Feedback:
Administering antidiarrheal agents on a regular schedule may be more beneficial than administering
them on an as-needed basis, provided the patients diarrhea is not caused by an infectious microorganism.
Increased oral fluid may exacerbate diarrhea; IV fluid replacement is often indicated. Small, more
frequent meals may be beneficial, and it is unrealistic to increase activity while the patient has frequent
diarrhea.

81

A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately
asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best
response?
A) Do you think that you might already have HIV?
B) Dont worry. Your immune system is likely very healthy.
C) AIDS isnt transmitted by casual contact.
D) You cant contract AIDS in a hospital setting.

Ans: C
Feedback:
AIDS is commonly transmitted by contact with blood and body fluids. Patients, family, and friends must
be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily
a protection against HIV. A hospital setting does not necessarily preclude HIV infection.

82

A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing
intervention best addresses this risk?
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A) Utilize a pressure-reducing mattress.
B) Limit the patients physical activity.
C) Apply antibiotic ointment to dependent skin surfaces.
D) Avoid contact with synthetic fabrics.

Ans: A
Feedback:
Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin
breakdown. Activity should be promoted, not limited, and contact with synthetic fabrics does not
necessary threaten skin integrity. Antibiotic ointments are not normally used unless there is a break in
the skin surface.

83

An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be
born with HIV. What is the nurses best response?
A) There is no way to know that for certain, but we do know that your baby has a one in four chance
of being born with HIV.
B) Your physician is likely the best one to ask that question.
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C) If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to
worry about it now.
D) Its possible that your baby could contract HIV, either before, during, or after delivery.

Ans: D
Feedback:
Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or
through breast-feeding. There is no evidence that the infants risk is 25%. Deferral to the physician is not
a substitute for responding appropriately to the patients concern. Downplaying the patients concerns is
inappropriate.

84

A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle
should guide the nurses choice of educational interventions?
A) Many older adults do not see themselves as being at risk for HIV infection.
B) Many older adults are not aware of the difference between HIV and AIDS.
C) Older adults tend to have more sex partners than younger adults.
D) Older adults have the highest incidence of intravenous drug use.

Ans: A
Feedback:
It is known that many older adults do not see themselves as being at risk for HIV infection. Knowledge
of the relationship between HIV infection and AIDS is not known to affect the incidence of new cases.
The statements about sex partners and IV drug use are untrue.

85

A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs
and the teen responds that she has become sexually active and is concerned about getting HIV. The teen
asks the nurse what she can do keep from getting HIV. What would be the nurses best response?
A) Theres no way to be sure you wont get HIV except to use condoms correctly.
B) Only the correct use of a female condom protects against the transmission of HIV.
C) There are new ways of protecting yourself from HIV that are being discovered every day.
D) Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV

Ans: D
Feedback:
Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the
risk of sexual transmission of HIV infection. Both female and male condoms confer significant
protection. New prevention techniques are not commonly discovered, though advances in treatment are
constant.

86

A patient is in the primary infection stage of HIV. What is true of this patients current health status?
A) The patients HIV antibodies are successfully, but temporarily, killing the virus.
B) The patient is infected with HIV but lacks HIV-specific antibodies.
C) The patients risk for opportunistic infections is at its peak.
D) The patient may or may not develop long-standing HIV infection.

Ans: B
Feedback:
The period from infection with HIV to the development of HIV-specific antibodies is known as primary
infection. The virus is not being eradicated and infection is certain. Opportunistic infections emerge
much later in the course of the disease.

87

A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels
and the patients immune response. This physiologic state is known as which of the following?
A) Static stage
B) Latent stage
C) Viral set point
D) Window period

Ans: C
Feedback:
The remaining amount of virus in the body after primary infection is referred to as the viral set point,
which results in a steady state of infection that lasts for years. This is not known as the static or latent
stage. The window period is the time a person infected with HIV tests negative even though he or she is
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infected.

88

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

Ans: B
Feedback:
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.

89

A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What
nursing action is most likely to increase the likelihood of successful therapy?
A) Promoting appropriate use of complementary therapies
B) Addressing possible barriers to adherence
C) Educating the patient about the pathophysiology of HIV
D) Teaching the patient about the need for follow-up blood work

Ans: B
Feedback:
ART is highly dependent on adherence to treatment, and the nurse should proactively address this. Blood
work is necessary, but this will not have a direct bearing on the success or failure of treatment.
Complementary therapies are appropriate, but are not the main factor in successful treatment. The
patient may or may not benefit from teaching about HIV pathophysiology.

90

The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the
patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the
nurses most appropriate action?
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A) Assess the patient for additional signs and symptoms of Kaposis sarcoma.
B) Review the patients most recent viral load and CD4+ count.
C) Place the patient on respiratory isolation and inform the physician.
D) Perform oral suctioning to reduce the patients risk for aspiration.

Ans: C
Feedback:
These signs and symptoms are suggestive of tuberculosis, not Kaposis sarcoma; prompt assessment and
treatment is necessary. There is no indication of a need for oral suctioning and the patients blood work
will not reflect the onset of this opportunistic infection.

91

A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patients
CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle?
A) Integration
B) Attachment
C) Cleavage
D) Budding

Ans: B
Feedback:
During the process of attachment, glycoproteins of HIV bind with the hosts uninfected CD4+ receptor
and chemokine coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane.
Integration, cleavage, and budding are steps that are subsequent to this initial phase of the HIV life
cycle.

92

An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45
cells/mL, and the nurse recognizes the patients increased risk for Mycobacterium aviumcomplex (MAC
disease). The nurse should anticipate the administration of what drug?
A) Azithromycin
B) Vancomycin
C) Levofloxacin
D) Fluconazole

Ans: A
Feedback:
HIV-infected adults and adolescents should receive chemoprophylaxis against
disseminatedMycobacterium avium complex (MAC disease) if they have a CD4+ count less than 50
cells/L. Azithromycin (Zithromax) or clarithromycin (Biaxin) are the preferred prophylactic agents.
Vancomycin, levofloxacin, and fluconazole are not prophylactic agents for MAC.

93

A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for
this patient should expect the physician to order what drug for the management of the patients diarrhea?
A) Zithromax
B) Sandostatin
C) Levaquin
D) Biaxin

Ans: B
Feedback:
Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to
be effective in managing chronic severe diarrhea. Zithromax, Levaquin, and Biaxin are not used to treat
chronic severe diarrhea.

94

A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related
anorexia. What drug has been found to promote significant weight gain in AIDS patients by increasing
body fat stores?
A) Advera
B) Momordicacharantia
C) Megestrol
D) Ranitidine

Ans: C
Feedback:
Megestrol acetate (Megace), a synthetic oral progesterone preparation, promotes significant weight gain.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 706
In patients with HIV infection, it increases body weight primarily by increasing body fat stores. Advera
is a nutritional supplement that has been developed specifically for people with HIV infection and AIDS.
Momordicacharantia (bitter melon) is given as an enema and is part of alternative treatment for
HIV/AIDS. Ranitidine prevents ulcers.

95

A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related
complications. What components should the nurse include in this assessment? Select all that apply.
A) Serum albumin level
B) Weight history
C) White blood cell count
D) Body mass index
E) Blood urea nitrogen (BUN) level

Ans: A, B, D, E
Feedback:
Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere
with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the
patients ability to purchase and prepare food is assessed. Weight history (i.e., changes over time);
anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin
levels provide objective measurements of nutritional status. White cell count is not a typical component
of a nutritional assessment.

96

A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the
nurse should prioritize assessment of what skin surfaces?
A) Perianal region and oral mucosa
B) Sacral region and lower abdomen
C) Scalp and skin over the scapulae
D) Axillae and upper thorax

Ans: A
Feedback:
The nurse should inspect all the patients skin surfaces and mucous membranes, but the oral mucosa and
perianal region are particularly vulnerable to skin breakdown and fungal infection.

97

A hospital nurse has experienced percutaneous exposure to an HIV-positive patients blood as a result of
a needlestick injury. The nurse has informed the supervisor and identified the patient. What action
should the nurse take next?
A) Flush the wound site with chlorhexidine.
B) Report to the emergency department or employee health department.
C) Apply a hydrocolloid dressing to the wound site.
D) Follow up with the nurses primary care provider.

Ans: B
Feedback:
After initiating the emergency reporting system, the nurse should report as quickly as possible to the
employee health services, the emergency department, or other designated treatment facility. Flushing is
recommended, but chlorhexidine is not used for this purpose. Applying a dressing is not recommended.
Following up with the nurses own primary care provider would require an unacceptable delay.

98

The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity.
What nursing intervention should be included in the plan of care?
A) Maximize the patients fluid intake.
B) Provide total parenteral nutrition (TPN).
C) Keep the patients bed linens free of wrinkles.
D) Provide the patient with snug clothing at all times.

Ans: C
Feedback:
Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and
avoiding tight or restrictive clothing. Fluid intake should be adequate, and must be monitored, but
maximizing fluid intake is not a goal. TPN is a nutritional intervention of last resort.

99

A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention
would be appropriate for this patient?
A) Position the patient in the high Fowlers position whenever possible.
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B) Temporarily eliminate animal protein from the patients diet.
C) Make sure the patient eats at least two servings of raw fruit each day.
D) Obtain a stool culture to identify possible pathogens.

Ans: D
Feedback:
A stool culture should be obtained to determine the possible presence of microorganisms that cause
diarrhea. Patients should generally avoid raw fruit when having diarrhea. There is no need to avoid
animal protein or increase the height of the patients bed.

100

A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety.
What would be the most appropriate nursing intervention?
A) Teach the patient guided imagery.
B) Give the patient more control of her antiretroviral regimen.
C)
Increase the patients activity level.
D) Collaborate with the patients physician to obtain an order for hydromorphone.

Ans: A
Feedback:
Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which
contributes to weakness and fatigue. Increased activity may be of benefit, but for other patients this may
exacerbate feelings of anxiety or loss. Granting the patient control has the potential to reduce anxiety,
but the patient is not normally given unilateral control of the ART regimen. Hydromorphone is not used
to treat anxiety.

101

A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing
diagnosis should the nurse associate with this complication of AIDS?
A) Risk for Disuse Syndrome Related to Kaposis Sarcoma
B)
Impaired Skin Integrity Related to Kaposis Sarcoma
C)
Diarrhea Related to Kaposis Sarcoma
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D) Impaired Swallowing Related to Kaposis Sarcoma

Ans: B
Feedback:
Kaposis sarcoma (KS) is a disease that involves the endothelial layer of blood and lymphatic vessels.
This malignancy does not directly affect swallowing or bowel motility and it does not constitute a risk
for disuse syndrome.

102

A nurse is performing the admission assessment of a patient who has AIDS. What components should
the nurse include in this comprehensive assessment? Select all that apply.
A) Current medication regimen
B) Identification of patients support system
C) Immune system function
D) Genetic risk factors for HIV
E) History of sexual practices

Ans: A, B, C, E
Feedback:
Nursing assessment includes numerous focuses, including identification of medication use, support
system, immune function and sexual history. HIV does not have a genetic component.

103

A female patient with HIV has just been diagnosed with condylomata acuminata (genital warts). What
information is most appropriate for the nurse to tell this patient?
A) This condition puts her at a higher risk for cervical cancer; therefore, she should have a
Papanicolaou (Pap) test annually.
B) The most common treatment is metronidazole (Flagyl), which should eradicate the problem within
7 to 10 days.
C) The potential for transmission to her sexual partner will be eliminated if condoms are used every
time they have sexual intercourse.
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D) The human papillomavirus (HPV), which causes condylomata acuminata, cannot be transmitted
during oral sex.

Ans: A
Feedback:
HIV-positive women have a higher rate of HPV. Infections with HPV and HIV together increase the risk
of malignant transformation and cervical cancer. Thus, women with HIV infection should have frequent
Pap smears. Because condylomata acuminata is a virus, there is no permanent cure. Because
condylomata acuminata can occur on the vulva, a condom will not protect sexual partners. HPV can be
transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.

104

A middle-aged female patient has been offered testing for HIV/AIDS upon admission to the hospital for
an unrelated health problem. The nurse observes that the patient is visibly surprised and embarrassed by
this offer. How should the nurse best respond?
A) Most women with HIV dont know they have the disease. If you have it, its important we catch it
early.
B) This testing is offered to every adolescent and adult regardless of their lifestyle, appearance or
history.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1085
C) The rationale for this testing is so that you can begin treatment as soon as testing comes back, if its
positive.
D) Youre being offered this testing because you are actually in the prime demographic for HIV
infection.

Ans: B

Feedback:

Because patients may be reluctant to discuss risk-taking behavior, routine screening should be offered to

all women between the ages of 13 to 64 years in all health care settings. Assuring a woman that the offer

of testing is not related to a heightened risk may alleviate her anxiety. Middle-aged women are not the

prime demographic for HIV infection. The nurse should avoid causing fear by immediately discussing

treatment or the fact that many patients are unaware of their diagnosis.

105

A patient with human immunodeficiency virus (HIV) has sought care because of the recent development
of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what?
A) A reduction in the patients CD4 count
B) A reduction in the patients viral load
C) An adverse effect of antiretroviral therapy
D) Virus-induced changes in allergy status

Ans: A
Feedback:
Cutaneous signs may be the first manifestation of human immunodeficiency virus (HIV), appearing in
more than 90% of HIV-infected people as immune function deteriorates. These skin signs correlate with
low CD4 counts and may become very atypical in immunocompromised people. Viral load increases,
not decreases, as the disease progresses. Antiretrovirals are not noted to cause cutaneous changes and
viruses do not change an individuals allergy status.

106

A nurse is providing care for a patient who has developed Kaposis sarcoma secondary to HIV infection.
The nurse should be aware that this form of malignancy originates in what part of the body?
A) Connective tissue cells in diffuse locations
B) Smooth muscle cells of the gastrointestinal and respiratory tract
C) Neural tissue of the brain and spinal cord
D) Endothelial cells lining small blood vessels

Ans: D
Feedback:
Kaposis sarcoma (KS) is a malignancy of endothelial cells that line the small blood vessels. It does not
originate in connective tissue, smooth muscle cells of the GI and respiratory tract, or in neural tissue.

107

Family members are caring for a patient with HIV in the patients home. What should the nurse
encourage family members to do to reduce the risk of infection transmission?
A) Use caution when shaving the patient.
B) Use separate dishes for the patient and family members.
C) Use separate bed linens for the patient.
D) Disinfect the patients bedclothes regularly.

Ans: A
Feedback:
When caring for a patient with HIV at home, family members should use caution when providing care
that may expose them to the patients blood, such as shaving. Dishes, bed linens, and bedclothes, unless
contaminated with blood, only require the usual cleaning.