Chapter 11: Care of Patient with HIV/AIDS My Nursing Test Banks

Chapter 11: Care of Patient with HIV/AIDS

MULTIPLE CHOICE

1. The nurse speaking with a student about immunocompetence correctly defines it as occurring when:

a.

there has been an overwhelming allergic reaction.

b.

the immune system cannot differentiate between foreign cells and the bodys own cells.

c.

the individual is exposed to a disease from which he has no immunity.

d.

physiologic responses protect the body against invasion from microorganisms or toxins.

ANS: D

Immunocompetence means that the immune system is reacting to the threat of invasion of microorganisms or toxins by initiating physiologic responses by the vascular system, initiation of chemical responses, or the release of white blood cells.

DIF: Cognitive Level: Comprehension REF: 215 OBJ: 4 (theory)

TOP: The Immune System KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse recognizes a need for further instruction when the HIV-positive patient says:

a.

My life is over. HIV and AIDS are the same thing.

b.

I can delay having full-blown AIDS if I change my lifestyle.

c.

Drug protocols can keep me relatively healthy for many years.

d.

I am aware that unsafe sex is a risk factor I ignored.

ANS: A

HIV does sometimes develop into full-blown AIDS, but they are not the same thing. Drugs and changes in lifestyle can delay the onset of AIDS, and the patient may lead a healthy life for many years. Unsafe sex is commonly a causative factor for transmission of HIV.

DIF: Cognitive Level: Application REF: 215 OBJ: 2 (theory)

TOP: HIV Infection KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. In caring for the patient who is HIV positive, the nurse should:

a.

wear gown, gloves, and mask at all times.

b.

limit visitors.

c.

monitor intake of salt.

d.

use Standard Precautions.

ANS: D

Standard Precautions are adequate during routine nursing care. For invasive procedures, additional personal protective equipment is necessary.

DIF: Cognitive Level: Application REF: 217 OBJ: 6 (theory)

TOP: HIV Precautions KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. The nurse is aware that more instruction is needed for the HIV-positive patient when she says:

a.

Latex condoms are the best.

b.

I could give my partner HIV without practicing safe sex.

c.

I should avoid pregnancy.

d.

Oral sex is safer and doesnt require a barrier.

ANS: D

Oral sex with a patient who is HIV positive requires an oral barrier.

DIF: Cognitive Level: Comprehension REF: 217 OBJ: 1 (theory)

TOP: Safe Sex KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. The nurse clarifies that the HIV virus enters and alters the DNA of the _____ cell lymphocyte.

a.

B

b.

T

c.

CD4

d.

killer T

ANS: C

The HIV virus attaches to the CD4 cell lymphocyte.

DIF: Cognitive Level: Comprehension REF: 217 OBJ: 1 (theory)

TOP: CD4 Lymphocyte KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

6. When oral thrush, recurrent vaginal yeast infections, or skin disorders appear in the HIV-positive patient, the nurse assesses this as:

a.

AIDS.

b.

invasion of primary pathogens.

c.

a sign of a failing immune system.

d.

retrovirus infection.

ANS: C

Sentinel infections are opportunistic infections that may indicate underlying immunosuppression in the HIV-infected patient. It is not a definitive sign that AIDS has occurred, nor are these classified as primary pathogens. HIV is a retrovirus that incorporates itself into the genetic material of the host cells it infects, thus altering the DNA.

DIF: Cognitive Level: Application REF: 219 OBJ: 2 (theory)

TOP: Sentinel Infection KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. The nurse describes the initial diagnostic test for HIV as the enzyme-linked immunosorbent assay (ELISA), which is performed to detect:

a.

human immunodeficiency virus.

b.

depleted phagocytes.

c.

numbers of T helper cells.

d.

HIV antibodies.

ANS: D

The ELISA looks for HIV antibodies. There is no test that can detect the HIV virus itself.

DIF: Cognitive Level: Application REF: 219 OBJ: 1 (theory)

TOP: Diagnostic Tests for HIV KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. The nurse uses a visual aid to demonstrate how nonnucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) work to combat HIV by:

a.

interfering with replication of the virus.

b.

stimulating production of CD4 helper cells.

c.

making a hostile environment for the virus.

d.

dissolving the virus.

ANS: A

Both types of drugs interfere with the replication of the virus.

DIF: Cognitive Level: Comprehension REF: 222 | Table 11-3

OBJ: 1 (theory) TOP: Treatment of HIV

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The nurse caring for a patient with AIDS who is taking cidofovir (Vistide) for a cytomegalovirus retinitis will modify the care plan to include:

a.

provision of cool baths to reduce skin irritation.

b.

provision of milk-based drinks to reduce gastritis.

c.

teaching direction in the use of an incentive spirometer to reduce pleural effusion.

d.

increasing fluid intake to reduce possible nephrotoxicity.

ANS: D

Cidofovir (Vistide) can be toxic to the kidneys. Increasing fluid intake will reduce the threat of nephrotoxicity. In addition, intravenous hydration with normal saline should be administered with each infused dose of cidofovir. Skin irritation, gastritis, and pleural effusion are not associated with this drug.

DIF: Cognitive Level: Application REF: 223 OBJ: 2 (theory)

TOP: Treatment for AIDS: Vistide KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

10. The hospitalized patient with an HIV infection who is being treated for Mycobacterium tuberculosis (MTb) demonstrates understanding of care when stating:

a.

I am fortunate that I will not need to be in transmission-based precautions for this infection.

b.

My family will have to get special testing because the normal PPD test is not used to detect exposure to this infection.

c.

It is important for me to take my rifampin medication for the next year.

d.

This infection will only cause problems with my lungs.

ANS: C

Rifampin therapy usually lasts for a minimum of 6 to 12 months. Transmission-based precautions are necessary for MTb. PPD testing can be used for screening of MTb. MTb can affect other areas, such as the central nervous system, GI tract, and spleen.

DIF: Cognitive Level: Analysis REF: 223 OBJ: 2 (theory)

TOP: Treatment of HIV: Rifampin KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

11. The nurse is aware that Pneumocystis jiroveci (P. carinii, or PCP) becomes a real threat when the immunosuppressed patients CD4 count drops to _____ cells/mm3.

a.

200

b.

400

c.

600

d.

1000

ANS: A

Pneumocystis jiroveci is considered an opportunistic infection in the patient who is HIV positive. When the CD4 count drops to 200 cell/mm3, the HIV-positive patient is vulnerable to opportunistic infections.

DIF: Cognitive Level: Application REF: 224 OBJ: 3 (theory)

TOP: Risks: PCP KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

12. The nurse will add a special caution to patient teaching for a patient with HIV infection who has a _____ for a house pet.

a.

dog

b.

cat

c.

bird

d.

gerbil

ANS: B

Toxoplasma gondii is a protozoan that can be passed to immunocompromised individuals, causing toxoplasmosis. Domestic and wild cats may carry the organism, thus passing the organism via their feces, potentially infecting the patient with this organism. The patient should not empty the cat litter box. Wild game, lamb, and venison are also carriers of the organism.

DIF: Cognitive Level: Application REF: 224 OBJ: 3 (theory)

TOP: Risks: Toxoplasmosis KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

13. In the event of an accidental exposure to HIV through a needle stick, the nurse should be given a protocol of 1 to 3 drugs for a period of _____ weeks.

a.

4

b.

8

c.

12

d.

16

ANS: A

The protocol should be taken for a period of 4 to 6 weeks.

DIF: Cognitive Level: Comprehension REF: 230 | Safety Alert

OBJ: 1 (theory) TOP: Risks: Possible Exposure to HIV

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The nurse includes in the discharge instructions to a patient with HIV the need to make fresh disinfectant solution daily using 1 cup of household bleach mixed with _____ cups of water.

a.

2

b.

6

c.

10

d.

12

ANS: C

The bleach solution should be made fresh daily of 1 cup of household bleach to 10 cups of water to use as a disinfectant for urine, feces, sputum, or blood spills.

DIF: Cognitive Level: Comprehension REF: 228 OBJ: 1 (theory)

TOP: Disinfectant Solution KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

15. The nurse caring for a patient with advanced AIDS notes that the patient has lost several pounds as the result of having no appetite and poor food consumption. Based on these findings, what should the nurse be alert to?

a.

Lymphedema

b.

Hyperglycemia

c.

Hypertension

d.

Anasarca

ANS: D

Anasarca is generalized edema in the trunk, extremities, and around the eyes. It results in patients with advanced AIDS from a severe depletion of albumin when the patient has an insufficient nutritional intake, as is evident with this patient. Lymphedema is an abnormal collection of lymph fluid accumulated in the peripheral and periorbital areas, sometimes seen in AIDS patients. Hypoglycemia and hypotension are typically seen in patients with advanced AIDS who have poor nutritional and fluid intake.

DIF: Cognitive Level: Analysis REF: 226 OBJ: 3 (theory)

TOP: Advanced AIDS: Symptoms KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. The nurse is caring for an immune compromised patient who complains of itching and tingling from below the shoulder on the back around to the chest area, as well as burning and shooting pain, headache, and low-grade fever. The nurse is aware that this patient is most likely experiencing:

a.

hepatitis C.

b.

shingles.

c.

a bacterial infection.

d.

cryptococcosis.

ANS: B

The immune compromised patient may experience opportunistic infections. Hepatitis C, bacterial infections, and cryptococcosis are all opportunistic infections, but the symptoms this patient is experiencing are consistent with shingles.

DIF: Cognitive Level: Application REF: 223 OBJ: 4 (theory)

TOP: Opportunistic Infection KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The physician explains to a patient that the frequent infections he has been experiencing are caused by insufficient production of antibodies and immune cells. The nurse is aware that the physician is describing what type of disorder?

a.

Immune deficiency

b.

Autoimmune disease

c.

Opportunistic infection

d.

Recurrent infection

ANS: A

There are two main types of disorders of the immune system: (1) immune deficiency, which is an insufficient production of antibodies, immune cells, or both; and (2) autoimmune disease, which is when the immune system is unable to tell the difference between non-self (foreign cells) and self (the bodys own cells). Opportunistic infections and recurrent infections typically occur as a result of immune deficiency disorders.

DIF: Cognitive Level: Comprehension REF: 215 OBJ: 4 (theory)

TOP: Immune Deficiency KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A patient states that she has heard of two types of HIV and asks the nurse what the difference is between HIV type 1 and HIV type 2. Which response by the nurse is correct?

a.

HIV type 1 is the more severe classification of HIV.

b.

HIV type 2 is a retrovirus.

c.

There is only one type of HIV, not types 1 and 2.

d.

HIV type 1 is the most common type seen in the United States.

ANS: D

HIV-1 is the most common cause of HIV infection in the United States, Europe, and Asia. HIV-2 is widespread in western Africa. Research has also shown that HIV-2 spreads at a lower rate, has a lower plasma viral load, and takes longer to incubate, and those infected with this strain have a lesser risk of developing full-blown AIDS. Both types of HIV are retroviruses.

DIF: Cognitive Level: Application REF: 217 OBJ: 1 (theory)

TOP: Types of HIV KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

19. An HIV patient has lost more than 10% of her weight along with having diarrhea for the last 30 days. The nurse knows that these are indications of:

a.

AIDS.

b.

wasting syndrome.

c.

an opportunistic infection.

d.

anorexia.

ANS: B

Wasting syndrome is a physiologic problem associated with HIV infection. It is defined as losing more than 10% of weight along with at least 30 days of either diarrhea or weakness accompanied by fever. The patient loses not only body fat but also muscle mass. It is often an indication of progression of the HIV infection.

DIF: Cognitive Level: Comprehension REF: 229 OBJ: 7 (theory)

TOP: Wasting Syndrome KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The nurse is caring for an AIDS patient who has been experiencing fatigue, anorexia, weight loss, and occasional nausea/vomiting. Which nursing diagnosis is the priority for this patient?

a.

Fatigue

b.

Imbalanced nutrition: Less than body requirements

c.

Activity intolerance

d.

Ineffective health maintenance

ANS: B

With all of these factors, the most appropriate nursing diagnosis would be Imbalanced nutrition: Less than body requirements. Interventions can be directed toward restoring nutrition, which may lead to less fatigue and weight loss.

DIF: Cognitive Level: Analysis REF: 227 | Table 11-5

OBJ: 6 (theory) TOP: Nursing Diagnosis

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

21. The nurse is working in a trauma unit and is accidentally stuck with an IV needle following venipuncture of the patient. What is the nurses first action?

a.

Immediately begin taking the two- or three-drug regimen.

b.

Report the stick to the charge nurse immediately so follow-up can be initiated.

c.

Wash the punctured area with soap and water.

d.

Complete an incident report so immediate testing of the patient and nurse can begin.

ANS: C

The area should first be cleansed in an attempt to flush any pathogenic organisms from the site, followed by reporting the incident to the charge nurse and completing an incident report. Appropriate treatment regimen will then be started.

DIF: Cognitive Level: Application REF: 230 | Safety Alert

OBJ: 9 (theory) TOP: HIV Exposure

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

22. An HIV-positive patient is diagnosed with Kaposi sarcoma (KS). The patient asks why highly active antiretroviral therapy (HAART) is being prescribed for him. Which response by the nurse is most accurate?

a.

HAART will help stop the progression of your skin lesions.

b.

HAART will prevent you from getting AIDS.

c.

HAART will treat any current opportunistic infections you have.

d.

HAART will eliminate your HIV.

ANS: A

KS is a common malignancy in HIV-positive patients and appears as discolored areas on the skin, but can also form inside of the mouth, lungs, and intestines. HAART can stop the progression of skin lesions in some patients and may even eliminate the lesions. HAART can slow the progression of HIV, but cannot eliminate the HIV infection or the possibility of progression into AIDS. Antibiotics are used to treat infections.

DIF: Cognitive Level: Application REF: 225 OBJ: 2 (clinical)

TOP: HAART KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

MULTIPLE RESPONSE

23. Research shows that 73% of new HIV cases are seen in the minority population largely because of: (Select all that apply.)

a.

lack of high-quality, culturally sensitive information about HIV and its prevention.

b.

cultural beliefs about sex practices.

c.

cost of HIV preventative medications.

d.

reduced access to health care.

e.

lack of intelligence.

ANS: A, B, C, D

All options, except the last option, lend themselves to the spread of HIV in minority populations.

DIF: Cognitive Level: Application REF: 218 | Cultural Considerations

OBJ: 1 (theory) TOP: HIV Infection: Cultural Aspect

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

24. To plan an effective Education for Prevention of HIV teaching outline, the nurse must assess the intended patient population for: (Select all that apply.)

a.

likelihood of contracting HIV.

b.

level of understanding of the virus.

c.

approximate educational level.

d.

incidence of infection in area.

e.

risk factors practiced.

ANS: B, C, D, E

Likelihood of contracting HIV is often difficult to determine, so the teaching plan should be consistent for all persons.

DIF: Cognitive Level: Analysis REF: 229-230 OBJ: 1 (theory)

TOP: HIV Prevention KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

25. The school nurse instructing a group of high school sophomores in safe sex practices should include which practice(s) in her teaching? (Select all that apply.)

a.

Use a condom.

b.

Use a spermicide.

c.

Practice abstinence.

d.

Get vaccinated against HIV.

e.

Avoid unprotected orogenital sex.

ANS: A, C, E

HIV can be transmitted by sexual practices of not using a condom and through orogenital sex. Abstinence is the only way to ensure that HIV is not transmitted through sexual intercourse. Spermicides do not prevent HIV transmission, and there is no vaccination against HIV.

DIF: Cognitive Level: Application REF: 218 OBJ: 1 (theory)

TOP: Safe Sex KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

26. The nurse is providing patient education to the patient newly diagnosed with HIV. When explaining sentinel infections to the patient, the nurse should include which infection? (Select all that apply.)

a.

Oral thrush

b.

Recurrent vaginal yeast infections

c.

Skin infections

d.

Tuberculosis

e.

Encephalopathy

ANS: A, B, C

Sentinel infections are opportunistic infections that may indicate underlying immunosuppression. Tuberculosis and encephalopathy are considered category C AIDS defining infections.

DIF: Cognitive Level: Application REF: 219 OBJ: 4 (theory)

TOP: Opportunistic Infection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

27. The nurse stresses that the primary emphasis on controlling HIV is __________.

ANS:

prevention

Prevention of HIV infections is the major key to controlling HIV infections.

DIF: Cognitive Level: Knowledge REF: 218 OBJ: 1 (theory)

TOP: HIV Infection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

28. The patient with AIDS voices concern over the amount of money it will cost to manage his disease. The nurse is aware that it is estimated that medications and lab testing cost an average of $______ per year for the patient with AIDS.

ANS:

25000

25,000

It is estimated that medications and lab testing for a patient with AIDS will cost at least $25,000.

DIF: Cognitive Level: Knowledge REF: 220 OBJ: 2 (theory)

TOP: Diagnosis of AIDS KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

MATCHING

Arrange the process of HIV invasion in the proper sequence.

a.

HIV attaches to CD4 receptor sites on helper T cells.

b.

Opportunistic infection occurs.

c.

Infected cell replicates itself millions of times.

d.

T helper cells fail to activate phagocytes.

e.

Immune system is unable to respond effectively.

29. Step 1

30. Step 2

31. Step 3

32. Step 4

33. Step 5

29. ANS: A DIF: Cognitive Level: Analysis REF: 217 | Table 11-1

OBJ: 1 (theory) TOP: HIV Infection KEY: Nursing Process Step: NA

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. ANS: C DIF: Cognitive Level: Analysis REF: 217 | Table 11-1

OBJ: 1 (theory) TOP: HIV Infection KEY: Nursing Process Step: NA

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

31. ANS: D DIF: Cognitive Level: Analysis REF: 217 | Table 11-1

OBJ: 1 (theory) TOP: HIV Infection KEY: Nursing Process Step: NA

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

32. ANS: E DIF: Cognitive Level: Analysis REF: 217 | Table 11-1

OBJ: 1 (theory) TOP: HIV Infection KEY: Nursing Process Step: NA

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

33. ANS: B DIF: Cognitive Level: Analysis REF: 217 | Table 11-1

OBJ: 1 (theory) TOP: HIV Infection KEY: Nursing Process Step: NA

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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