Medsurg 2 - exam 3 Questions & Answers 100% Accurate

The nurse is caring for a client diagnosed with HIV-II. The client's CD4+ cell count is 399/mm3 (0.399 109/L). 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. - ANSWER-ANS: A This client is in the Centers for Disease Control and Prevention HIV-II case definition group. He or she remains highly infectious and would be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required, although some medications may need to be taken while abstaining. 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 precedence over stopping the spread of the disease. The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse - ANSWER-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 in addition to providing mucus membrane contact with the virus. 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 (1 m) of the client - ANSWER-ANS: A