ATI Care of Clients with HIV Disease and Other Immune Deficiencies, Questions and Answers with Explanations

1. 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.

ANS: 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 Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

2. 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 iguana’s cage from now on.”

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

c.             “It will seem funny but I’ll run my toothbrush through the dishwasher.”

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

ANS: 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

3. 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 nurse’s 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.”

ANS: 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 Potential—Laboratory Values) MSC: Integrated Process: Teaching/Learning

4. 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

ANS: 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 Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

5. 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 client’s 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 client’s pupil reaction.

ANS: B

The client’s 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 Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

6. 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 client’s liquids to honey consistency.

d.            Administer IV pentamidine isethionate (Pentam).

ANS: 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 Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

7. A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The client’s 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 client’s chest x-ray.

c.             Initiate a 3-day calorie count.

d.            Start an IV of normal saline.

ANS: A

The client’s symptoms are indicative of tuberculosis (TB). With AIDS, the client’s 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 Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Analysis)

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Category ATI
Release date 2021-09-14
Pages 15
Language English
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