Chapter 19: Care of Patients with HIV Disease Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9edition

MULTIPLE CHOICE 1. The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals. ANS: A This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease. DIF: Applying/Application REF: 339 KEY: HIV/AIDS| safer sex| immune disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 2. The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse ANS: A Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus. DIF: Understanding/Comprehension REF: 341 KEY: HIV/AIDS| safer sex| infection| immune disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client ANS: A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact