HIV NCLEX

Created by abberz88 

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1. A patient who seeks health care for vague symptoms of fatigue and headaches has HIV testing and is found to have a positive enzyme immunoassay (EIA) for HIV antibodies. In discussing the test results with the patient, the nurse informs the patient that
a. the enzyme immunoassay test will need to be repeated to verify the results.
b. a viral culture will be done to determine the progress of the disease.
c. it will probably be 10 or more years before the patient develops AIDS.
d. the Western blot test will need to be done to determine whether AIDS has developed.

a. the enzyme immunoassay test will need to be repeated to verify the results.
b. a viral culture will be done to determine the progress of the disease.
c. it will probably be 10 or more years before the patient develops AIDS.
d. the Western blot test will need to be done to determine whether AIDS has developed.

A
Rationale: After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not part of HIV testing. Because the nurse does not know how recently the patient was infected, it is not appropriate to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.

Cognitive Level: Application Text Reference: p. 256
Nursing Process: Implementation NCLEX: Physiological Integrity

Four years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and a low viral load. The nurse teaches the patient that
a. the patient is at risk for development of opportunistic infections because of CD4+
cell destruction.
b. the patient is in a clinical and biologic latent period, during which very few viruses are being replicated.
c. anti-HIV antibodies produced by B cells enter CD4+ cells infected with HIV to stop replication of viruses in the cells.
d. the body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity.

D
Rationale: The patient is the early chronic stage of infection, when the body is able to produce enough CD4+ cells to maintain the CD4+ count at a normal level. The risk for opportunistic infection is low because of the normal CD4+ count. Although the viral load in the blood is low, intracellular reproduction of virus still occurs. Anti-HIV antibodies produced by B cells attack the viruses in the blood, but not intracellular viruses.


Cognitive Level: Application Text Reference: pp. 252, 257
Nursing Process: Implementation NCLEX: Physiological Integrity

A patient who tested positive for HIV 3 years ago is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP). Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), the patient is diagnosed as having
a. early chronic infection.
b. HIV infection.
c. AIDS.
d. intermediate chronic infection.

C
Rationale: Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other responses indicate an earlier stage of HIV infection than is indicated by the PCP infection.

Cognitive Level: Comprehension Text Reference: p. 253
Nursing Process: Assessment NCLEX: Physiological Integrity

During posttest counseling for a patient who has positive testing for HIV, the patient is anxious and does not appear to hear what the nurse is saying. At this time, it is most important that the nurse
a. inform the patient how to protect sexual and needle-sharing partners.
b. teach the patient about the medications available for treatment.
c. ask the patient to notify individuals who have had risky contact with the patient.
d. remind the patient about the need to return for retesting to verify the results.

D
Rationale: After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.

Cognitive Level: Application Text Reference: pp. 256, 264
Nursing Process: Implementation NCLEX: Psychosocial Integrity

A patient who is diagnosed with AIDS and has developed Kaposi's sarcoma tells the nurse, "I have lots of thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is most appropriate?
a. "Thinking about dying will not improve the course of AIDS."
b. "Although your diagnosis is serious, there are more treatments available now."
c. "Try to focus on the good things in life because stress impairs the immune system."
d. "Tell me what kind of thoughts you have about dying."

D
Rationale: More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "Try to focus on the good things in life ..." discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. The statement, "Although your diagnosis is serious, there are more treatments available now" is correct, but without further assessment, it is impossible to know whether this responds to the patient's concerns.

Cognitive Level: Application Text Reference: pp. 260, 265, 267
Nursing Process: Implementation NCLEX: Psychosocial Integrity

A pregnant woman with a history of asymptomatic HIV infection is seen at the clinic. Which information will the nurse include when teaching the patient?
a. Although infants of HIV-infected mothers always test positive for HIV antibodies, most infants are not infected with the virus.
b. Because she has not developed AIDS, the infant will not contract HIV during intrauterine life.
c. The infant will be started on zidovudine (AZT) after delivery to prevent HIV infection.
d. It is likely that her newborn will develop HIV infection unless she takes antiretroviral drugs during the pregnancy.

A
Rationale: Because antibodies are transmitted from the mother to the fetus during intrauterine life, all infants of HIV-positive mothers will test positive at birth. Ongoing antibody (or viral) testing is needed to determine whether the infant is infected with HIV. Transmission of the virus can occur during fetal life even if the mother does not have AIDS. Infants of HIV-positive mothers are not routinely started on antiretroviral therapy (ART). Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy.

Cognitive Level: Application Text Reference: p. 250
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

Interventions such as promotion of nutrition, exercise, and stress reduction should be promoted by the nurse for patients who have HIV infection, primarily because these interventions will
a. promote a feeling of well-being in the patient.
b. prevent transmission of the virus to others.
c. improve the patient's immune function.
d. increase the patient's strength and self-care ability.

C
Rationale: The primary goal for the patient with HIV infection is to increase immune function, and these interventions will promote a healthy immune system. They may also promote a feeling of well-being and increase strength, but these are not the priority goals for HIV-positive patients. These activities will not prevent the risk for transmission to others because the patient will still be HIV positive.

Cognitive Level: Comprehension Text Reference: p. 265
Nursing Process: Planning NCLEX: Physiological Integrity

The occupational health nurse will teach the nursing staff that the highest risk of acquiring HIV from an HIV-infected patient is
a. a needlestick with a suture needle during a surgical procedure.
b. contamination of open skin lesions with vaginal secretions.
c. a needlestick with a needle and syringe used to draw blood.
d. splashing the eyes when emptying a bedpan containing stool.

C
Rationale: Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

Cognitive Level: Comprehension Text Reference: p. 250
Nursing Process: Assessment
NCLEX: Safe and Effective Care Environment

A patient has recently tested positive for HIV and asks the nurse about drug therapy for HIV infection. The nurse informs the patient that
a. drug therapy for HIV is indicated only for patients whose CD4+ cell counts indicate that AIDS has developed.
b. medication therapy is delayed as long as possible to prevent development of viral resistance to the drugs.
c. treatment is individualized based on CD4+ counts, the amount of virus in the blood, and the patient's wishes.
d. ART is typically started soon after HIV diagnosis to prevent progression of the disease.

C
Rationale: ART is typically considered when the CD4+ count drops below normal levels or the viral load is high in patients who are appropriate for ART and desire ART. ART is used to prevent the progression to AIDS and is used in patients who have AIDS. ART is not delayed as long as possible but can be started when the CD4+ counts are relatively high in some patients. ART is not started soon after HIV diagnosis; rather, it is started when CD4+ count, viral load, or patient symptoms indicate that it will be beneficial.

Cognitive Level: Application Text Reference: pp. 256-257
Nursing Process: Implementation NCLEX: Physiological Integrity

Drug therapy is being considered for an HIV-infected patient who has a CD4+ cell count of 400/µl. The nursing assessment that is most important in determining whether therapy will be used is the patient's
a. social support system offered by significant others and family.
b. socioeconomic status and availability of medical insurance.
c. understanding of the multiple side effects that the drugs may cause.
d. willingness and ability to comply with stringent medication schedules.

D
Rationale: Drug resistance develops quickly unless the patient takes multiple drugs on a stringent schedule, and this endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.

Cognitive Level: Comprehension Text Reference: pp. 264-265
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

Which of these patients will the nurse working in an HIV testing and treatment clinic anticipate teaching about ART?
a. A patient who is HIV negative but has unprotected sex with multiple partners
b. A patient who has been HIV positive for 5 years and has cytomegalovirus (CMV) retinitis
c. A patient who was infected with HIV 15 years ago and has a CD4 count of 740/µl
d. An HIV-positive patient with a CD4 count of 120/µl who drinks a fifth of whiskey daily

B
Rationale: CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not require ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.

Cognitive Level: Application Text Reference: p. 253
Nursing Process: Planning NCLEX: Physiological Integrity

When teaching a patient with HIV infection about ART, the nurse explains that these drugs
a. work in various ways to decrease viral replication in the blood.
b. boost the ability of the immune system to destroy the virus.
c. destroy intracellular virus as well as lowering the viral load.
d. increase the number of CD4+ cells available to fight the HIV.

A
Rationale: The three groups of antiretroviral drugs work in different ways to decrease the ability of the virus to replicate. The drugs do not work by boosting the ability of the immune system or CD4 cells to fight the virus. The viral load detected in the blood is decreased with effective therapy, but intracellular virus is still present.

Cognitive Level: Application Text Reference: pp. 256-257
Nursing Process: Implementation NCLEX: Physiological Integrity

When assessing an individual who has been diagnosed with early chronic HIV infection and has a normal CD4+ count, the nurse will
a. ask about problems with diarrhea.
b. examine the oral mucosa for lesions.
c. check neurologic orientation.
d. palpate the regional lymph nodes.

D
Rationale: Persistent generalized lymphadenopathy is common in the early stage of chronic infection. Diarrhea, oral lesions, and gait abnormalities would occur in the later stages of HIV infection.

Cognitive Level: Application Text Reference: p. 252
Nursing Process: Assessment NCLEX: Physiological Integrity

While teaching community groups about AIDS, the nurse informs people that the most common method of transmission of the HIV virus currently is
a. perinatal transmission to the fetus.
b. sharing equipment to inject illegal drugs.
c. transfusions with HIV-contaminated blood.
d. sexual contact with an infected partner.

D
Rationale: Sexual contact with an infected partner is currently the most common mode of transmission, although HIV is also spread through perinatal transmission, through sharing drug injection equipment, and through transfusions with HIV-infected blood.

Cognitive Level: Comprehension Text Reference: p. 250
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

A 24-year-old woman who uses injectable illegal drugs asks the nurse about preventing AIDS. The nurse informs the patient that the best way to reduce the risk of HIV infection from drug use is to
a. participate in a needle-exchange program.
b. clean drug injection equipment before use.
c. ask those who share equipment to be tested for HIV.
d. avoid sexual intercourse when using injectable drugs.

A
Rationale: Participation in needle-exchange programs has been shown to control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced by individuals in withdrawal. HIV antibodies do not appear for several weeks to months after exposure, so testing drug uses would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

Cognitive Level: Comprehension Text Reference: pp. 262-263
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

At the health promotion level of care for HIV infection, which question is most appropriate for the nurse to ask?
a. "Are you having any symptoms such as severe weight loss or confusion?"
b. "Are you experiencing any side effects from the antiretroviral medications?
c. "Do you need any assistance to obtain antiretroviral drugs or other treatments?"
d. "Do you use any injectable drugs or have sexual activity with multiple partners?"

D
Rationale: At the health-promotion level, the nurse screens for behaviors that might increase the risk for HIV infection and implements interventions to prevent infection (or, in the case of an already infected patient, implement interventions to prevent progression of the disease to AIDS). The other questions would be appropriate at the acute intervention level, when the patient already has significant immune compromise.

Cognitive Level: Application Text Reference: pp. 260-261
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

A patient with HIV infection has developed Mycobacterium avium complex infection. An appropriate outcome for the patient is that the patient will
a. be free from injury.
b. maintain intact perineal skin.
c. have adequate oxygenation.
d. receive immunizations.

B
Rationale: The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc) associated with HIV infection.

Cognitive Level: Analysis Text Reference: p. 255
Nursing Process: Planning NCLEX: Physiological Integrity

A patient who has been treated for HIV infection for 7 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. The nurse will anticipate teaching the patient about
a. treatment with antifungal agents.
b. a change in antiretroviral therapy.
c. foods that are higher in protein.
d. the benefits of daily exercise.

B
Rationale: A frequent first intervention for metabolic disorders is a change in ART. Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

Cognitive Level: Application Text Reference: pp. 266-267
Nursing Process: Planning NCLEX: Physiological Integrity

The nurse is preparing to give the following medications to an HIV-positive patient who is hospitalized with PCP. Which is most important to administer at the right time?
a. Nystatin (Mycostatin) tablet for vaginal candidiasis
b. Aerosolized pentamadine (NebuPent) for PCP infection
c. Oral acyclovir ((Zovirax to treat systemic herpes simplex
d. Oral saquinavir (Inverase) to suppress HIV infection

D
Rationale: It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

Cognitive Level: Application Text Reference: pp. 258, 264-265
Nursing Process: Implementation NCLEX: Physiological Integrity

To evaluate the effectiveness of ART, the nurse will schedule the patient for
a. viral load testing.
b. enzyme immunoassay.
c. rapid HIV antibody testing.
d. immunofluorescence assay.

A
Rationale: The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect for HIV antibodies, which remain positive even with effective ART.

Cognitive Level: Application Text Reference: p. 265
Nursing Process: Planning NCLEX: Physiological Integrity

When designing a program to decrease the incidence of HIV infection in the community, the nurse will prioritize education about
a. how to prevent transmission between sexual partners.
b. methods to prevent perinatal HIV transmission.
c. ways to sterilize needles used by injectable drug users.
d. means to prevent transmission through blood transfusions.

A
Rationale: Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide education about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

Cognitive Level: Application Text Reference: pp. 250, 260-263
Nursing Process: Planning NCLEX: Physiological Integrity

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