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)
Category | ATI |
Release date | 2021-09-14 |
Pages | 15 |
Language | English |
Comments | 0 |
Sales | 0 |
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