NURS 4212 STUDY GUIDE/REVIEWER/PRACTICE QUESTIONS 2024. WITH 100% CORRECT AND VERIFIED ANSWERS. LATEST 2024 UPDATE, GUARANTEED A+ SCORE.

Professionalism in nursing ATI leadership Chapter one managing client care Critical thinking Assigning, delegating, and supervising 1. A nurse enters the room of a client and finds the client lying on the floor. Which of the following actions should the nurse take first? a. Call the provider b. ask a staff member for assistance getting the client back in bed c. inspect the client for injuries d. instruct the client to ask for help if they need to get out of bed 2. An RN on a medical surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the PN? a. Obtain vital signs for a client who is 2 hours post procedure following a cardiac catheterization b. Administer a unit of packed red blood cells to a client who has cancer c. instruct a client who is scheduled for discharge in the performance of wound care d. develop a plan of care for a newly admitted client who has pneumonia 3. A PN ending their shift reports to the RN that a newly hired AP has not calculated the intake and output for several clients. Which of the following actions should the RN take? a. Complete an incident report b. Delegate this task to the PN c. Ask the AP if they need assistance d. Notify the nurse manager 4. A nurse manager is developing an Orientation plan for newly licensed nurses. Which of the following information should the manager include in the plan? SATA a. Skill proficiency b. Assignment to preceptor c. Budgetary principles d. Computerized charting e. Socialization into unit culture f. Facility policies and procedures 5. A nurse manager is providing information about the audit process to the members of the nursing team. Which of the following information should the nurse manager include? SATA a. a structure audit evaluates the setting and resources available to provide care b. an outcome audit evaluates the results of the nursing care provided c. a root cause analysis is indicated when a sentinel event occurs d. Retrospective audits are conducted while the client is receiving care e. after data collection is completed it is compared to a benchmark 6. A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following information will provide data regarding the efficacy of the procedure? a. frequency with which procedure is performed b. client satisfaction with performance of procedure c. incidence of complications related to procedure d. accurate documentation of how procedure was performed 7. a nurse is hired to replace a staff member who has resigned. After working on the unit for several weeks the nurse notices that the unit manager does not intervene when there is conflict between team members even when it escalates which of the following conflict resolution strategies is the unit manager demonstrating a. avoidance b. smoothing c. cooperating d. negotiating chapter 2 coordinating client care 1. a nurse is preparing to transfer a client who is 72 hours postoperative to a long term care facility. Which of the following information should the nurse include in the transfer report? a. Type of Anesthesia used b. advance directive status c. vital signs on day of admission d. medical diagnosis e. need for specific equipment 2. a nurse is assisting with the discharge planning for a client. Which of the following actions should the nurse take? SATA a. Determine the clients need for home medical equipment b. provide a list of all the medications the client received in the facility c. obtain printed instructions for medication self administration d. provide the family with a list of community agencies that can provide assistance e. discuss the importance of attending follow up appointments 3. a case manager is discussing critical pathways with a group of newly hired nurses. Which of the following statements indicates understanding? a. The time to fill out the pathway often increases the cost of care b. the pathway shows an estimate of the number of days the client will be hospitalized c. deviants from the pathway as a sign of improved care quality d. the pathway includes information about the client's history 4. a nurse who has just assumed the role of unit manager is examining the skills necessary for interprofessional collaboration. Which of the following actions support the nurses interprofessional collaboration? SATA a. Use aggressive communication when addressing the team b. recognize the knowledge and skills of each team member c. ensure that a nurse assigned to serve as the group facilitator for all interprofessional meetings. d. encourage the client and family to participate in the team meeting e. support team member request for referral 5. a nurse is caring for a client who has chest pain. The client says I am going home immediately. Which of the following actions should the nurse take? SATA a. Notify the clients family of their intent to leave the facility b. document the client’s intent to leave the facility AMA c. explain to the client the risks involved if they choose to leave d. ask the client to sign a form relinquishing responsibility of the facility e. prevent the client from leaving the facility until the provider arrives o Delegation ▪ Applying the five rights of delegation and supervision • Right task o Should require little supervision o Should be relatively noninvasive • Right circumstance o Complexity of care should match the skill level of the team member o Consider team member workload • Right person o Team member should be competent o Should have the necessary credentials/scope of practice • Right direction and communication o Must be clear what data needs to be collected o How that data must be reported o Specific tasks to be performed o Expected results, timelines, expectations for follow-up reporting • Right supervision and evaluation o Delegator must supervise (directly or indirectly) o Provide clear directions as above o Monitor performance o Provide feedback o Intervene if necessary o Evaluate patient and determine if goals were met ▪ Delegating to other team members (UAP, LPN, other RNs) based on scope of practice • Nurses can only delegate tasks appropriate for the skill and education level of the health care provider who is receiving the assignment • Cannot delegate the nursing process (clinical judgement, patient education or tasks that require nursing judgement to LPN’s or UAPs • LPN—reinforcement of teaching, trach care, suctioning, NGT patency, admin of meds/enteral feedings, insertion of foley • UAP- ADLs, bathing, toileting, ambulation, feeding, positioning, specimen collection, I&O, VS o When to assume care of client vs. assigning or delegating to other personnel ▪ From what I understood, assigning care means completely giving away the care to another nurse and you are no longer held accountable for that patient's care. Delegating care is when you ask someone else to do a task for you, understanding that if anything goes wrong you are still held accountable for that patient's care. o Prioritizing nursing diagnoses and client care based on assessment findings and the different prioritization frameworks (Maslow’s, ABCs [airway, breathing, circulation], etc.) ▪ Physiological is first ▪ Airway ▪ Breathing ▪ Circulation ▪ Disability ▪ Exposure ▪ Pt. is wheezing from long standing asthma but her foot is purple following surgery to that limb. Circulation becomes priority ▪ Least restrictive or invasive first ▪ Survival potential • Do not Delegate what you can EAT o Evaluate o Assess o Treat • Nurses can only delegate tasks appropriate for the skill and education level of the health care provider who is receiving the assignment • CANNOT delegate the nursing process (clinical judgment) patient education or tasks that require nursing judgment to LPN or UAPs • EXAMPLES OF TASKS TO DELEGATE LPN UAP Reinforcement teaching ADLs and VS Trach care Bathing and toileting Suctioning Ambulation Check NGT patency Feeding Administration of enteral feedings/meds Positioning Insertion of foley Specimen collection and I&Os 1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse? 1. Attending to holistic client needs 2. Ensuring client safety 3. Not making medication errors 4. Providing client-focused care ANS: B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are several national and international organizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client’s safety. The other actions are important for quality nursing, but they are not as vital as providing safety. Not making medication errors does provide safety, but is too narrow in scope to be the best answer. 2. A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety? 1. Encourage the client and family to be active partners. 2. Have the client monitor hand hygiene in caregivers. 3. Offer the family the opportunity to stay with the client. 4. Tell the client to always wear his or her armband. ANS: A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a safety partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does. 3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first? 1. Call the Rapid Response Team. 2. Document and continue to monitor. 3. Notify the primary health care provider. 4. Repeat the blood pressure in 15 minutes. ANS: A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours’ urine output are particularly significant and are part of the Modified Early Warning System guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client’s blood pressure would be reassessed frequently, but the priority is getting the rapid care to the client. 4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? 1. Assesses for cultural influences affecting health care. 2. Ensures that all the client’s basic needs are met. 3. Tells the client and family about all upcoming tests. 4. Thoroughly orients the client and family to the room. ANS: A Showing respect for the client and family’s preferences and needs is essential to ensure a holistic or “whole-person” approach to care. By assessing the effect of the client’s culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered care. 5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? 1. Bring a list of all medications and what they are for. 2. Keep the provider’s phone number by the telephone. 3. Make sure that all providers wash hands before entering the room. 4. Write down the name of each caregiver who comes in the room. ANS: A Medication reconciliation is a formal process in which the client’s actual current medications are compared to the prescribed medications at the time of admission, transfer, or discharge. This National client Safety Goal is important to reduce medication errors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider’s phone number nearby and documenting everyone who enters the room also do not guarantee safety. 6. Which action by the nurse working with a client best demonstrates respect for autonomy? 1. Asks if the client has questions before signing a consent. 2. Gives the client accurate information when questioned. 3. Keeps the promises made to the client and family. 4. Treats the client fairly compared to other clients. ANS: A Autonomy is self-determination. The client would make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice. 7. A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? 1. Avoid embarrassing the client by asking questions. 2. Don’t make assumptions about his or her health needs. 3. Most LGBTQ people do not want to share information. 4. No differences exist in communicating with this population. ANS: B Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly. 8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? 1. “I would like you to order a different pain medication.” 2. “This client has allergies to morphine and codeine.” 3. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.” 4. “This client had a vaginal hysterectomy 2 days ago.” ANS: B SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated; the client’s surgery 2 days ago would be considered background. Assessment would include an analysis of the client’s problem; none of the options has assessment information. Asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired. 9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the AP was much higher than previous readings, and the client’s mental status has changed. What action by the nurse would most likely have prevented this negative outcome? 1. Determining if the AP knew how to take blood pressure 2. Double-checking the AP by taking another blood pressure 3. Providing more appropriate supervision of the AP 4. Taking the blood pressure instead of delegating the task ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the AP. 10. A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best? 1. “All staff nurses are required to participate in quality improvement here.” 2. “Even being new, you can implement activities designed to improve care.” 3. “It’s easy to identify what indicators would be used to measure quality.” 4. “You should ask to be assigned to the research and quality committee.” ANS: B The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice. 11. A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best? 1. Ask the hospitals there about standard nurse–client ratios. 2. Choose the hospital that has the newest technology. 3. Find a hospital that has achieved Magnet status. 4. Work in a facility affiliated with a medical or nursing school. ANS: C Client Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses can demonstrate how best current evidence guides their practice. New technology doesn’t necessarily mean that the hospital is safe. Affiliation with a health profession school has several advantages, but safety is most important. MULTIPLE RESPONSE 1. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) 1. Collaborating with an interprofessional team 2. Implementing evidence-based care 3. Providing family-focused care 4. Routinely using informatics in practice 5. Using quality improvement in client care 6. Formalizing systems thinking when implementing care ANS: A, B, D, E The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interprofessional team, implementing evidence-based practice, providing patient-focused care, using informatics in client care, and using quality improvement in client care. Systems thinking is required for quality improvement but is not a specified part of the IOM report. 2. A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) 1. Consults with other disciplines on client care. 2. Coordinates discharge planning for home safety. 3. Participates in comprehensive client rounding. 4. Routinely asks other disciplines about client progress. 5. Shows the nursing care plans to other disciplines. 6. Delegate tasks to unlicensed personnel appropriately. ANS: A,B,C,D,F Collaborating with the interprofessional team involves planning, implementing, and evaluating client care as a team with all other involved disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them. 3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) 1. Cost-saving measures 2. Nurse’s expertise 3. Client preferences 4. Research findings 5. Values of the client 6. Plan-do-study-act model ANS: B, C, D, E EBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’s expertise when planning care. It does not include cost-saving measures. The PDSA model is a systematic model for quality improvement, but is not a specific component of EBP. 4. A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) 1. Attend hand-off rounds to coach and mentor. 2. Create a template of suggested topics to include in report. 3. Encourage staff to ask questions during hand-off. 4. Give raises based on compliance with reporting. 5. Provide education on the SBAR method of communication ANS: A, B, C, E The SBAR method of communication has been identified as an excellent method of communication between health care professionals. It is a formalized structure consisting of Situation, Background, Assessment, and Recommendation/Request. Using a formalized mechanism for communication helps ensure successful hand-off and fewer client errors. When establishing this new format for report, the most helpful actions by the manager would be to provide initial education on the process, develop a template with suggested topics under each heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify information. Basing raises on compliance would not be the most helpful method because raises are often determined only once a year and are based on multiple criteria. Fundamentals ch. 7, 8, 9 Look at pictures IMMUNITY LECTURE • Innate or natural immunity o Barriers (skin, mucus membranes) o Inflammation • Adaptive immunity o Antibody-mediated immunity o Cell-mediated immunity • Immunocompetency : Inflammation, antibody-mediated, cell-mediated all must work together Innate Immunity: • Stages of Acute inflammation: o STAGE 1: VASCULAR STAGE ▪ Release of histamines and kinins constrict veins, dilate arterioles to increase blood flow to area ▪ Capillaries leaky allow inflammatory cells and mediators to site of injury ▪ Causes EDEMA ▪ Macrophage, starts to phagocytose foreign organisms and sends cytokines to call for more WBC and neutrophils • Stage II: Cellular exudate ▪ Neutrophils to site of injury d/t cytokine release ▪ Exudate forms from debris (purulent drainage) • Stage III: tissue repair/replacement ▪ May result in scar, decreased function Adaptive Immunity (specific immunity): • Antibody mediated Immunity: aka Humoral immunity o B cells o Antibodies are made by sensitized B cells o Memory B-cells in case encounter antigen again o How B cells become part of adaptive immune response: ▪ 1. Exposure ▪ 2. Antigen recognition ▪ 3. Sensitization ▪ 4. Antibody production/release ▪ 5. Antibody-antigen binding ▪ 6. Inactivation of organism with antigen ▪ Agglutination ▪ Lysis ▪ Complement activation and fixation ▪ Inactivation ▪ 7. Sustained immunity (memory) • Cell mediated immunity o T cells, natural killer cells (NK) o Suppressor T cells (Ts, T8) control immune response to protect the host o Cell-mediated immunity process : ▪ Antigens presented to T-helper cells by B cells, dendritic or macrophages ▪ Cells that present antigens to Th are called “antigen presenting cells or APCs) • T helper cells then help recruit and develop specific immunity • T memory cells formed: rapidly recruit and initiate specific response to another exposure of same antigen in future • Cell mediated immunity protects by differentiating self from non self • CMI most easily recognizes cancer as non self • Also recognizes some self cells infected by viruses or parasites for example Patho and examples of type 1-4 hypersensitivity Type I: rapid/immediate Type 2: cytotoxic Type 3: Immune complex reactions Type 4: cell- mediated hypersensitivity Systemic anaphylacis and localized anaphylaxis such as hay fever, asthma, hives, food allergies, eczema Blood transfusion reactions, erythroblastosis fetalis, autoimmune hemolytic anemia Localized arthus reaction and generalized reactions such as serum sickness, necrotizing vasculitis, glomerulonephritis, rheumatoid arthritis, systemic lupus erythematosus Contact dermatitis (poison ivy, latex), tubercular lesions, graft rejection, sarcoidosis, IV drug reactions (antibiotics) RHEUMATOID ARTHRITIS patho -Body makes antibodies that attack synovium, articular cartilage, joint capsule, ligaments, tendons -Synovium thickens -Fluid accumulates in joints -pannus forms: granulation tissue in synovial membrane that forms as result of autoimmune attack -more blood vessels form in synovial membrane perpetuating inflammatory process -bone damage-can be permanent -damage can be avoided with early intervention Risk factors -female -Age 20-50, then older age -genetic -epstein-barr virus -environmental possibly-smoke, silica, insecticides -exacerbations linked to stress Signs and symptoms Early: -weakness, fatigue -fever persistent low grade -anorexia, weight loss -joints stiff, red, tender, painful swollen and warm-usually hands first -joint involvement is usually bilateral and symmetric -pain at rest and w/movement -Late: -progressive inflammation -^pain -morning stiffness (gel phenomenon) lasts 45 min to several hours -joints soft and puffy -joint deformity and lack of function Labs -Erythrocyte Sedimentation Rate (ESR): measure of general inflammation, may test again to see response to treatment -rheumatoid factor (RF) -Anti-nuclear antibody (ANA) -C-reactive Protein (CRP): may be done in place of ESR Treatment -NSAIDS-antiinflammatory properties -COX-2 inhibitor (celecoxib)-subclass NSAIDs-fewer GI SE but cardiac risk -corticosteroids: not long term d/t side effects such as immunosuppression, osteoporosis and cataracts -DMARDs: cytotoxic/immunosuppressants- avoid pregnancy -antimalarial (hydroxychloroquine) -antibiotic (minocycline) -Sulfonamide (sulfasalazine) -Plasmapheresis -synovectomy or total joint arthroplasty -Rest -exercise -Heat best for reducing stiffness and pain, Ice better for reducing edema -nutrition -CAM (ex: acupuncture, turmeric, fish oil, glucosamine and chondroitin Nursing care -assist w/ mobility, rom -apply heat or cold -encourage gentle exercise -cluster care -monitor labs -admin meds properly complications -Sjogren’s syndrome: decreased tears saliva and vaginal fluid: can cause visual disturbances and changes in vision -secondary osteoporosis (d/t steroid use) -vasculitis (organ ischemia) SLE Lupus Erythematosus PATHO -involves formation of autoantibodies, especially those that attack components of cell nucleus -immune system attacks DNA and RNA in nuclei causing build up of immune complexes in serum and in organs -initiation of inflammatory process damages organs with possible vasculitis RISK FACTORS -female -20-40 y/o age of onset -more common in POC -genetics SIGNS AND SYMPTOMS -fatigue -blurry vision -pain -photosensitivity -joint pain, w/o deformities -anorexia -depression -fever -anemia -butterfly rash -alopecia -muscle atrophy -pleural effusions -pericarditis -hematuria -peripheral edema -CNS: seizure, migraines -avascular necrosis of femur -tendon rupture LABS -CBC -BUN, creatinine -UA -immunologic tests: ANA, serum comploments c3, cr, ESR TREATMENT Meds: NSAIDs, corticosteroids, hydroxychloroquine, immunosuppressants NURSING CARE -monitor and treat pain -monitor for hypertension -monitor renal function -monitor resp -small frequent meals Educate: -avoid UV -protect against infection -s/s renal failure (peripheral edema, SOB, fatigue) -pregnancy risk factors from lupus meds COMPLICATION S -lupus nephritis -pericarditis -pleural effusion SCLERODERMA Scleroderma PATHO -involves both antibody and cell-mediated immune system -immune system attacks body structures -affected areas become sclerosed and fibrotic -often presents as skin or microvascular changes -classifications: -diffuse cutaneous systemic sclerosis-over most of body -limited cutaneous systemic sclerosis (milder)-distal to knees and elbows, may involve face and neck Patients with this type usually have CREST syndrome RISK FACTORS -female -25-55 -hx connective tissue disease -chemical exposure maybe MANIFESTATIONS/SIG NS AND SYMPTOMS -joint pain and stiffness -dysphagia -GERD -painless symmetric pitting edema of hands and fingers -carpal tunnel -loss skin elasticity -hiatal hernia -diminished peristalsis -raynaud’s -fibrosis of myocardium, lung alveoli -stone face -malignant hypertension -telangiectasia Remember CREST: C: calcinosis-calcium deposits in skin R: raynaud’s phenomenon E:esophageal dysfunction- acid reflux and decreased motility S: sclerodactyly -thickening and tightening of skin in fingers and hands T: telangiectasia -dilation of capillaries causing red marks on skin surface LABS General autoimmune labs like those of SLE TREATMENT Pharm treatment to slow progression often unsuccessful -systemic steroids and immunosuppressants in large doses -endothelin receptor antagonists (new class) (Bosentan)-for pulmonary arterial hypertension, can improve ability to exercise, slow worsening of symptoms -H2 receptor antagonists and antacids for GERD -NSAIDs for inflammation and joint pain NURSING CARE -monitor and treat pain -mild soap for skin -keep room warm enough to avoid raynaud’s -speech therapy for dysphagia -small frequent meals Educate: -s/s organ involvement -waer gloves and socks avoid being cols -dietary instructions avoid trigger foods for gerd -med adherence -avoid infection’ -stress and smoking can worsen symptoms -take meds with food COMPLICATIONS -fibrosis of myocardium -fibrosis of lungs-pulmonary hypertension -fibrosis of esophagus -fibrosis of intestines -renal failure-renal hypertension -medication complications-infection, eye damage HIV/AIDS HIV (not autoimmune) PATHO -enters blood stream via blood or bodily fluids-semen, vaginal fluids -uses helper T cells )Th) (CD4+lymphocytes) to replicate -binds to CD4 molecule to gain entry to cell -hijacks replicative machinery of cell and produces billions of virus particles -period of 1-3 months before HIV antibodies become detectable: window period - Stages: stage I: acute HIV infection -2-4 weeks after infection, flu like illness for a few weeks Stage 2: clinical latency (HIV inactivity or dormancy) -asymptomatic /chronic HIV, still active but produces at low levels Stage 3: acquired immunodeficiency syndrome (AIDS) -most severe, opportunistic infections occur RISK FACTORS -unprotected sex higher rates transmission when there are disruptions to mucosa -multiple partners -workplace exposure -sharing needles -blood transfusions (not so much anymore) -maternal HIV infection SIGNS AND SYMPTOMS -flu like symptoms -chills and night sweats -malaise anorexia, nausea -weakness -fatigue -HA -rash-usually flat and red -fever -cogh, sob -wasting syndrome -enlarged lymph nodes -poor wound healing -opportunistic infections LABS -CBC -CD4 (helper T) and CD8 (suppressor T) counts -ELISA -Western blot -PCR -viral load testing testing for other infections during initial workup: PPD CMV STDs Hep panel TREATMENT -Highly active antiretroviral therapy (HAART) • combination of 3 or more drugs • must take correctly 90% of time to be effective • goal: reduce viral load and slow progression -prevention: PREP-pre-exposure prophylaxis • HIV specific anti-retroviral drugs in HIV unaffected adult to prevent HIV infection • ongoing testing of renal function and HIV infection needed NURSING CARE -standard precautions -monitor weight, I&O -monitor lab values -precautions for immunocompromised patients -assess skin and provide care -educate: -med adherence -infection control -regular follow ups -support groups, psychosocial help available COMPLICATIONS -wasting syndrome -fluid electrolyte imbalance -opportunistic infections -kaposi sarcoma -end stage: AIDS related dementia OPPORTUNISTIC INFECTIONS Fungal infections TB Cytomegalovirus--HPV Kaposi’s sarcoma- lesions to grow in skin, lymph nodes, internal organs, mucous membranes lining the mouth, nose and throat Hodgkins lymphoma Cervical cancer Endocrine dysfunction AIDS CHAPTER 16, 17,18 IGGY 1. The nurse learns that the most important function of inflammation and immunity is which purpose? 1. Providing maximum protection against infection 2. A nurse is assessing an older client for the presence of infection. The client’s temperature is 97.6° F (36.4° C). What response by the nurse is best? 1. Assess the client for more specific signs. 3. A clinic nurse is working with an older client. What action is most important for preventing infections in this client? 1. Assessing vaccination records for booster shot needs 4. A client has a leg wound that is in Stage II of the inflammatory response. For what sign or symptom does the nurse assess? 1. Purulent drainage