AH3 EXAM 3 -IMMUNITY NCLEX QUESTIONS
The nurse is caring for a client with AIDS who is taking an antiretroviral medication. The
client complains of nausea, fever, severe diarrhea, and anorexia. Which of the following
medications would the nurse determine to be most effective to relieve the anorexia, as
well as to stimulate the client's appetite? Select all that apply.
A) Dronabinol (Marinol)
B) Zidovudine (Retrovir, AZT)
C) Abacavir (Ziagen)
D) Ciprofloxacin (Cipro)
E) Megestrol (Megace) - Answers :A) Dronabinol (Marinol)
E) Megestrol (Megace)
Rationale:
Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client's
appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication,
and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent
inhibitor of reverse transcriptase.
A new graduate nurse is performing an admission assessment on a client with
symptoms that indicate the client may have HIV. Which question does the nurse ask to
identify a major risk factor for contracting HIV?
A) "Has your partner been experiencing these symptoms?"
B) "Do you always practice safe sex?"
C) "Have you had any fever, diarrhea, or chills over the last 48 hours?"
D) "Have you ever experimented with intravenous drugs?" - Answers :D) "Have you
ever experimented with intravenous drugs?"
Rationale:
Use of recreational drugs, such as intravenous drugs, is a risk factor for contracting HIV.
Asking about safe sexual practices is important, but intravenous drug use would put the
client at greater risk for contracting HIV. The nurse cannot ask about the partner without
the partner's consent; however, if the partner were present and positive, it would be a
risk factor. Recent symptoms are not a risk factor.
The nurse is discharging an HIV-positive pediatric client who has recently developed
AIDS. The nurse is teaching the client's mother about health promotion activities for the
child. It is important for the nurse to tell the mother that the client should not receive
which immunizations due to HIV/AIDS status?
A) Varicella vaccine
B) Haemophilus influenzae type B (HIB conjugate vaccine)
C) Hepatitis B vaccine (hep B)
,D) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) - Answers :A)
Varicella vaccine
Rationale:
A child with an immune disorder such as HIV/AIDS should not be immunized with a live
varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and
hepatitis B vaccinations are not live vaccines, and should be given on schedule.
A nurse is developing a plan of care for a client who was recently diagnosed with HIV.
The client admits to being sexually active and states that he will remain sexually active.
Which would be a priority nursing diagnosis for this client based on this information?
A) Risk for Infection related to immunodeficiency
B) Death Anxiety
C) Deficient Knowledge related to preventing transmission of HIV
D) Social Isolation related to fear of AIDS - Answers :C) Deficient Knowledge related to
preventing transmission of HIV
Rationale:
All options are potential nursing diagnoses for this client. Deficient knowledge related to
preventing transmission of HIV would be the priority diagnosis for this client due to his
statement of wanting to remain sexually active. The client will need to be educated on
safer sex practices to decrease the risk of transmission to potential sexual partners.
The nurse is caring for a client who is newly diagnosed with HIV. The client asks the
nurse if there are ways to protect the client's sexual partner. Which client statement
indicates the need for further instruction?
A) "I know to use an oil-based lubricant to prevent spread of the disease to my partner."
B) "I know I can't donate blood anymore, as I have HIV."
C) "I will not share my toothbrush or razor with my partner."
D) "I know I have to practice safe sex with my partner by using a latex condom." -
Answers :A) "I know to use an oil-based lubricant to prevent spread of the disease to my
partner."
Rationale:
The nurse should educate the client regarding the prevention of the spread of HIV. The
client will need further education when he states that he will use an oil-based lubricant.
The client should be educated to use latex condoms for oral, vaginal, or anal
intercourse and to avoid natural or animal skin condoms, which allow passage of HIV.
The client should use only water-based lubricants-not oil-based, such as petroleum jelly,
which can result in condom damage. The client is correct in stating that it is not an
acceptable practice to share toothbrushes or razors. The client is also correct in stating
that blood donation is prohibited.
, The nurse is planning care for a pediatric client with HIV. The nurse selects Risk for
Infection as a priority nursing diagnosis for this client. Which interventions are
appropriate for a child with this diagnosis? Select all that apply.
A) Give frequent baths to the family dog.
B) Teach proper food-handling techniques to the family.
C) Provide ample fresh fruits and vegetables to bolster the immune system.
D) Assess the health status of all visitors.
E) Teach hand-washing techniques to the family. - Answers :B) Teach proper food-
handling techniques to the family.
D) Assess the health status of all visitors.
E) Teach hand-washing techniques to the family.
Rationale:
A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic
infections because of the effect of the virus on the immune system. The nurse teaches
the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent
infection. If there are pets, they should be kept outside, as they are a source of infection
to the child. Fresh fruits and vegetables are not recommended for a client with a
depressed immune system.
A client who has been diagnosed with untreated HIV comes in complaining of fatigue
and weight loss. What are some important elements of the physical exam for evaluating
the client's AIDS status? Select all that apply.
A) Assess the general appearance.
B) Assess skin color, temperature, and moisture.
C) Assess hair loss.
D) Inspect the skin for evidence of rashes or lesions.
E) Inspect the mouth for lesions. - Answers :A) Assess the general appearance.
B) Assess skin color, temperature, and moisture.
D) Inspect the skin for evidence of rashes or lesions.
E) Inspect the mouth for lesions.
Rationale:
Assess height, weight, and body type for apparent weight loss or wasting. Pallor may
indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions
may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth
lesions, which may have a "cottage cheese" appearance, may indicate candida.
The nurse is reviewing the laboratory values of a client who has been newly diagnosed
with AIDS. Which laboratory values would the nurse report to the physician? Select all
that apply.
A) CD4 cell count 1,100/mm3
The nurse is caring for a client with AIDS who is taking an antiretroviral medication. The
client complains of nausea, fever, severe diarrhea, and anorexia. Which of the following
medications would the nurse determine to be most effective to relieve the anorexia, as
well as to stimulate the client's appetite? Select all that apply.
A) Dronabinol (Marinol)
B) Zidovudine (Retrovir, AZT)
C) Abacavir (Ziagen)
D) Ciprofloxacin (Cipro)
E) Megestrol (Megace) - Answers :A) Dronabinol (Marinol)
E) Megestrol (Megace)
Rationale:
Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase the client's
appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication,
and zidovudine (Retrovir, AZT) is an antiretroviral agent. Abacavir (Ziagen) is a potent
inhibitor of reverse transcriptase.
A new graduate nurse is performing an admission assessment on a client with
symptoms that indicate the client may have HIV. Which question does the nurse ask to
identify a major risk factor for contracting HIV?
A) "Has your partner been experiencing these symptoms?"
B) "Do you always practice safe sex?"
C) "Have you had any fever, diarrhea, or chills over the last 48 hours?"
D) "Have you ever experimented with intravenous drugs?" - Answers :D) "Have you
ever experimented with intravenous drugs?"
Rationale:
Use of recreational drugs, such as intravenous drugs, is a risk factor for contracting HIV.
Asking about safe sexual practices is important, but intravenous drug use would put the
client at greater risk for contracting HIV. The nurse cannot ask about the partner without
the partner's consent; however, if the partner were present and positive, it would be a
risk factor. Recent symptoms are not a risk factor.
The nurse is discharging an HIV-positive pediatric client who has recently developed
AIDS. The nurse is teaching the client's mother about health promotion activities for the
child. It is important for the nurse to tell the mother that the client should not receive
which immunizations due to HIV/AIDS status?
A) Varicella vaccine
B) Haemophilus influenzae type B (HIB conjugate vaccine)
C) Hepatitis B vaccine (hep B)
,D) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) - Answers :A)
Varicella vaccine
Rationale:
A child with an immune disorder such as HIV/AIDS should not be immunized with a live
varicella vaccine, because of the risk of contracting the disease. DTaP, HIB, and
hepatitis B vaccinations are not live vaccines, and should be given on schedule.
A nurse is developing a plan of care for a client who was recently diagnosed with HIV.
The client admits to being sexually active and states that he will remain sexually active.
Which would be a priority nursing diagnosis for this client based on this information?
A) Risk for Infection related to immunodeficiency
B) Death Anxiety
C) Deficient Knowledge related to preventing transmission of HIV
D) Social Isolation related to fear of AIDS - Answers :C) Deficient Knowledge related to
preventing transmission of HIV
Rationale:
All options are potential nursing diagnoses for this client. Deficient knowledge related to
preventing transmission of HIV would be the priority diagnosis for this client due to his
statement of wanting to remain sexually active. The client will need to be educated on
safer sex practices to decrease the risk of transmission to potential sexual partners.
The nurse is caring for a client who is newly diagnosed with HIV. The client asks the
nurse if there are ways to protect the client's sexual partner. Which client statement
indicates the need for further instruction?
A) "I know to use an oil-based lubricant to prevent spread of the disease to my partner."
B) "I know I can't donate blood anymore, as I have HIV."
C) "I will not share my toothbrush or razor with my partner."
D) "I know I have to practice safe sex with my partner by using a latex condom." -
Answers :A) "I know to use an oil-based lubricant to prevent spread of the disease to my
partner."
Rationale:
The nurse should educate the client regarding the prevention of the spread of HIV. The
client will need further education when he states that he will use an oil-based lubricant.
The client should be educated to use latex condoms for oral, vaginal, or anal
intercourse and to avoid natural or animal skin condoms, which allow passage of HIV.
The client should use only water-based lubricants-not oil-based, such as petroleum jelly,
which can result in condom damage. The client is correct in stating that it is not an
acceptable practice to share toothbrushes or razors. The client is also correct in stating
that blood donation is prohibited.
, The nurse is planning care for a pediatric client with HIV. The nurse selects Risk for
Infection as a priority nursing diagnosis for this client. Which interventions are
appropriate for a child with this diagnosis? Select all that apply.
A) Give frequent baths to the family dog.
B) Teach proper food-handling techniques to the family.
C) Provide ample fresh fruits and vegetables to bolster the immune system.
D) Assess the health status of all visitors.
E) Teach hand-washing techniques to the family. - Answers :B) Teach proper food-
handling techniques to the family.
D) Assess the health status of all visitors.
E) Teach hand-washing techniques to the family.
Rationale:
A client with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic
infections because of the effect of the virus on the immune system. The nurse teaches
the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent
infection. If there are pets, they should be kept outside, as they are a source of infection
to the child. Fresh fruits and vegetables are not recommended for a client with a
depressed immune system.
A client who has been diagnosed with untreated HIV comes in complaining of fatigue
and weight loss. What are some important elements of the physical exam for evaluating
the client's AIDS status? Select all that apply.
A) Assess the general appearance.
B) Assess skin color, temperature, and moisture.
C) Assess hair loss.
D) Inspect the skin for evidence of rashes or lesions.
E) Inspect the mouth for lesions. - Answers :A) Assess the general appearance.
B) Assess skin color, temperature, and moisture.
D) Inspect the skin for evidence of rashes or lesions.
E) Inspect the mouth for lesions.
Rationale:
Assess height, weight, and body type for apparent weight loss or wasting. Pallor may
indicate bone marrow suppression with accompanying immunodeficiency. Skin lesions
may be indicative of Kaposi sarcoma. Hair loss is not usually related to AIDS. Mouth
lesions, which may have a "cottage cheese" appearance, may indicate candida.
The nurse is reviewing the laboratory values of a client who has been newly diagnosed
with AIDS. Which laboratory values would the nurse report to the physician? Select all
that apply.
A) CD4 cell count 1,100/mm3
