Exam (elaborations)
Caring for Clients with HIV/AIDS -Ch 35
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Caring for Clients with HIV/AIDS -Ch 35A nurse is teaching high school students about transmission of the human immunodeficiency virus
(HIV). Which comment by a student warrants clarification by the nurse?
"A man should wear a latex condom during intimate sexual contact."
"I've heard about people who got AIDS from blood transfusions."
"I won't donate blood because I don't want to get AIDS."
"I.V. drug users can get HIV from sharing needles." - ANS "I won't donate blood because I don't want
to get AIDS."
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related
dementia. Which nursing diagnosis takes highest priority?
Bathing or hygiene self-care deficit
Ineffective cerebral tissue perfusion
Complicated grieving
Risk for injury - ANS Risk for injury
Which blood test confirms the presence of antibodies to HIV?
Erythrocyte sedimentation rate (ESR)
p24 antigen
Reverse transcriptase
Enzyme immunoassay (EIA) - ANS Enzyme immunoassay (EIA)
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They
demonstrate understanding of the information when they state which of the following as the form
of the genetic viral material?
Deoxyribonucleic acid (DNA)
Ribonucleic acid (RNA)
Viral core
Glycoprotein envelope - ANS Ribonucleic acid (RNA)
A nurse is preparing to administer saquinavir, which is prescribed for a client who is HIV positive.
What type of drug does the nurse identify saquinavir as?
,Fusion inhibitor
Protease inhibitor (PI)
Non-nucleoside reverse transcriptase inhibitor (NNRTI)
Nucleoside reverse transcriptase inhibitor (NRTI) - ANS Protease inhibitor (PI)
The nurse is performing an admission assessment on a patient with AIDS. When assessing the
patient's gastrointestinal (GI) system what is most likely to be the priority nursing diagnosis?
Imbalanced nutrition: more than body requirements
Diarrhea
Bowel incontinence
Constipation - ANS Diarrhea
The period from infection with HIV to the development of antibodies to HIV is known as which of the
following?
Primary infection
Viral load
Viral set point
Anergy - ANS Primary infection
A client who is HIV/AIDS positive has orders for laboratory tests to be performed. What precautions
should the nurse observe whenever there is a risk of exposure to the blood and body fluids of an
infected client?
Avoid any physical contact with the client.
Avoid cleaning up spilled urine and feces.
Wear barrier garments for as long as possible after leaving a client's room.
Transport the specimens of body fluids in leak-proof containers. - ANS Transport the specimens of
body fluids in leak-proof containers.
A client requires a blood transfusion for anemia and is concerned about the risk of contracting
acquired immune deficiency syndrome (AIDS). What is the best response by the nurse?
"It is always a possibility."
"You don't want to die, do you?"
"The blood is screened very carefully; the risk is 1 in 2,000,000."
, "If you don't have the transfusion, you are taking a greater risk." - ANS "The blood is screened very
carefully; the risk is 1 in 2,000,000."
The nurse is preparing to start an IV for a client who is combative. What precautionary measure
should the nurse take in order to avoid a needlestick?
Have the patient placed in restraints.
Ask for assistance.
Refuse to start the IV.
Give the client a sedative prior to starting the IV. - ANS Ask for assistance
A client will be having a hysterectomy and wants her daughter to provide directed donor blood.
What factor would eliminate her daughter from donating the blood?
The daughter is 15 years of age.
The daughter weighs 124 lb.
The daughter is negative for HIV.
The physician has been notified of the procedure. - ANS The daughter is 15 years of age.
A nurse is working with a client who was diagnosed with HIV several months earlier. This client will
be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold?
75 cells/mm3 of blood
200 cells/mm3 of blood
325 cells/mm3 of blood
450 cells/mm3 of blood - ANS 200 cells/mm3 of blood
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 nurse's best response?
"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."
"Your physician is likely the best one to ask that question."
"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."
"It's possible that your baby could contract HIV, either before, during, or after delivery." - ANS "It's
possible that your baby could contract IV, either before, during, or after delivery."
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