HIV3
HIV3
HIV3
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
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Exam 5: HIV/AIDS (NCLEX)
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blood." What is the nurse's most appropriate action?
C
A) Assess the patient for additional signs and symptoms of Ka-
These signs and symptoms are suggestive of tuberculosis, not
posi's sarcoma.
Kaposi's sarcoma; prompt assessment and treatment is neces-
B) Review the patient's most recent viral load and CD4+ count.
sary. There is no indication of a need for oral suctioning and the
C) Place the patient on respiratory isolation and inform the physi-
patient's blood work will not reflect the onset of this opportunistic
cian.
infection.
D) Perform oral suctioning to reduce the patient's risk for aspira-
tion.
An HIV-infected patient presents at the clinic for a scheduled
CD4+ count. The results of the test are 45 cells/L, and the nurse
A
recognizes the patient's increased risk for Mycobacterium avium
HIV-infected adults and adolescents should receive chemopro-
complex (MAC disease). The nurse should anticipate the admin-
phylaxis against disseminated Mycobacterium avium complex
istration of what drug?
(MAC disease) if they have a CD4+ count less than 50 cells/µL.
Azithromycin (Zithromax) or clarithromycin (Biaxin) are the pre-
A) Azithromycin
ferred prophylactic agents. Vancomycin, levofloxacin, and flucona-
B) Vancomycin
zole are not prophylactic agents for MAC.
C) Levofloxacin
D) Fluconazole
A patient with AIDS is admitted to the hospital with AIDS-related
C
wasting syndrome and AIDS-related anorexia. What drug has
Megestrol acetate (Megace), a synthetic oral progesterone prepa-
been found to promote significant weight gain in AIDS patients by
ration, promotes significant weight gain. In patients with HIV in-
increasing body fat stores?
fection, it increases body weight primarily by increasing body fat
stores. Advera is a nutritional supplement that has been developed
A) Advera
specifically for people with HIV infection and AIDS. Momordi-
B) Momordicacharantia
cacharantia (bitter melon) is given as an enema and is part of
C) Megestrol
alternative treatment for HIV/AIDS. Ranitidine prevents ulcers.
D) Ranitidine
A nurse is completing a nutritional status of a patient who has ABDE
been admitted with AIDS-related complications. What compo- Nutritional status is assessed by obtaining a dietary history and
nents should the nurse include in this assessment? Select all that identifying factors that may interfere with oral intake, such as
apply. anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In
addition, the patient's ability to purchase and prepare food is
A) Serum albumin level assessed. Weight history (i.e., changes over time); anthropometric
B) Weight history measurements; and blood urea nitrogen (BUN), serum protein,
C) White blood cell count albumin, and transferrin levels provide objective measurements of
D) Body mass index nutritional status. White cell count is not a typical component of a
E) Blood urea nitrogen (BUN) level nutritional assessment.
A hospital nurse has experienced percutaneous exposure to an
HIV-positive patient's blood as a result of a needlestick injury. The B
nurse has informed the supervisor and identified the patient. What After initiating the emergency reporting system, the nurse should
action should the nurse take next? report as quickly as possible to the employee health services,
the emergency department, or other designated treatment facility.
A) Flush the wound site with chlorhexidine. Flushing is recommended, but chlorhexidine is not used for this
B) Report to the emergency department or employee health de- purpose. Applying a dressing is not recommended. Following up
partment. with the nurse's own primary care provider would require an
C) Apply a hydrocolloid dressing to the wound site. unacceptable delay
D) Follow up with the nurse's primary care provider.
The nurse care plan for a patient with AIDS includes the diagno-
sis of Risk for Impaired Skin Integrity. What nursing intervention C
should be included in the plan of care? Skin surfaces are protected from friction and rubbing by keeping
bed linens free of wrinkles and avoiding tight or restrictive clothing.
A) Maximize the patient's fluid intake. Fluid intake should be adequate, and must be monitored, but max-
B) Provide total parenteral nutrition (TPN). imizing fluid intake is not a goal. TPN is a nutritional intervention
C) Keep the patient's bed linens free of wrinkles. of last resort.
D) Provide the patient with snug clothing at all times.
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Exam 5: HIV/AIDS (NCLEX)
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A) Position the patient in the high Fowler's position whenever
possible.
presence of microorganisms that cause diarrhea. Patients should
B) Temporarily eliminate animal protein from the patient's diet.
generally avoid raw fruit when having diarrhea. There is no need
C) Make sure the patient eats at least two servings of raw fruit
to avoid animal protein or increase the height of the patient's bed.
each day.
D) Obtain a stool culture to identify possible pathogens.
A patient who has AIDS is being treated in the hospital and admits
A
to having periods of extreme anxiety. What would be the most
Measures such as relaxation and guided imagery may be bene-
appropriate nursing intervention?
ficial because they decrease anxiety, which contributes to weak-
ness and fatigue. Increased activity may be of benefit, but for other
A) Teach the patient guided imagery.
patients this may exacerbate feelings of anxiety or loss. Granting
B) Give the patient more control of her antiretroviral regimen.
the patient control has the potential to reduce anxiety, but the
C) Increase the patient's activity level.
patient is not normally given unilateral control of the ART regimen.
D) Collaborate with the patient's physician to obtain an order for
Hydromorphone is not used to treat anxiety.
hydromorphone.
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) ''I told the family members they needed to wash their hands
when they enter and leave the room.'' B
B) ''The other health care worker and I were out in the hallway Discussing this client's illness outside the client's room is a breach
discussing how we were concerned about getting HIV from our of confidentiality.
client, so no one could hear us in the client's room.''
C) ''Yes, I understand the reasons why I have to wear gloves when
I bathe my client.''
D) ''The client's spouse told me she got HIV from a blood trans-
fusion.
When preparing the newly diagnosed client with HIV and signif-
icant other for discharge, which explanation by the nurse accu-
rately describes proper condom use?
The blood test first used to identify a response to HIV infection is:
B
a. Western blot
b. ELISA test
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Exam 5: HIV/AIDS (NCLEX)
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c. CD4+ T-cell count
d. CBC
When teaching a patient infected with HIV regarding transmission
of the virus to others, which statement made by the patient would
indicate a need for further teaching?
A
A. "I will need to isolate any tissues I use so as not to infect my HIV is not spread casually. The virus cannot be transmitted
family." through hugging, dry kissing, shaking hands, sharing eating uten-
B. "I will notify all of my sexual partners so they can get tested for sils, using toilet seats, or attending school with an HIV-infected
HIV." person. It is not transmitted through tears, saliva, urine, emesis,
C. "Unprotected sexual contact is the most common mode of sputum, feces, or sweat.
transmission."
D. "I do not need to worry about spreading this virus to others by
sweating at the gym."
The nurse is providing care for a patient who has been living
with HIV for several years. Which assessment finding most clearly
indicates an acute exacerbation of the disease?
C
A. A new onset of polycythemia
B. Presence of mononucleosis-like symptoms
C. A sharp decrease in the patient's CD4+ count
D. A sudden increase in the patient's WBC count
A pregnant woman who was tested and diagnosed with HIV
infection is very upset. What should the nurse teach this patient
about her baby's risk of being born with HIV infection?
a. Droplet precautions
D
b. Contact precautions
c. Airborne precautions
d. Standard precautions
A 52-year-old female patient was exposed to human immunod-
eficiency virus (HIV) 2 weeks ago through sharing needles with
other substance users. What symptoms will the nurse teach the
patient to report that would indicate the patient has developed an
acute HIV infection?
A. Perinatal exposure
ADE
B. Pregnancy
C. Monogamous sex partner
D. Older adult woman
E. Occupational exposure
The nurse is admitting a client diagnosed with protein-calorie
malnutrition secondary to AIDS. Which intervention should be the
nurse's first intervention?
1. Assess the client's body weight and ask what the client has
been able to eat.
1
2. Place in contact isolation and don a mask and gown before
entering the room.
3. Check the HCP's orders and determine what laboratory tests
will be done.
4. Teach the client about total parenteral nutrition and monitor the
subclavianIV site.
The nurse presents a seminar on HIV testing to a group of seniors
and their caregivers in an assisted living facility. Which responses
fit the Centers for Disease Control and Prevention's (CDC's) rec-
ommendations for HIV testing? (Select all that apply.)
A) ''I am 78 years old and I was treated and cured of syphilis many
years ago.''
B) ''In 1986, I received a transfusion of platelets.'' ACF
C) ''Seven years ago, I was released from a penitentiary.''
D) ''I used to smoke marijuana 30 years ago, but I have not done
any drugs since.''
E) ''I had sex with a man with a disreputable past from New York
back in the late 1960s, but I have been happily married since
1971.''
F) ''At 68, I am going to get married for the fourth time.''
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