Chapter 17: Concepts of Care for Patients With HIV Disease
Medical-Surgical Nursing, 10th Edition
Ignatavicius:
1. 1. 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.: 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.
2. 2. 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: ANS: A
Anal intercourse is the riskiest sexual practice because the fragile anal
tissue can tear, creating a portal of entry for human immune
1/
, Chapter 17: Concepts of Care for Patients With HIV Disease
Medical-Surgical Nursing, 10th Edition
Ignatavicius:
deficiency virus in addition to providing mucus membrane contact with
the virus.
3. 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 (1 m) 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. Standard Precau- tions are required by the CDC. 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 (1 m) of the client is not
necessary with every client contact.
4. 4. A client with known HIV-II is admitted to the hospital with fever, night
sweats, and severe cough. Laboratory results include a CD4+ cell count of
180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What
action
2/
, Chapter 17: Concepts of Care for Patients With HIV Disease
Medical-Surgical Nursing, 10th Edition
Ignatavicius:
would the nurse take first?
a. Initiate Droplet Precautions for the client.
b. Notify the primary health care provider about the CD4+ results.
c. Place the client under Airborne Precautions.
d. Use Standard Precautions to provide care.: ANS: C
Since this client's CD4+ cell count is so low, he or she may have energy,
or the inability to mount an immune response to the TB test. The client
also appears to have progressed to HIV-III. The nurse would first place
the client on Airborne Precautions to prevent the spread of TB if it is
present. Next the nurse notifies the primary health care provider about
the low CD4+ count and requests alterative testing for TB. Droplet
Precautions are not used for TB. Standard Precautions are not adequate
in this case.
5. 5. A nurse is talking with a client about a negative enzyme-linked im-
munosorbent assay (ELISA) test for human immune deficiency virus (HIV).
The test is negative and the client states "Whew! I was really worried about
that result." What action by the nurse is most important? a. Assess the
client's sexual activity and patterns.
b. Express happiness over the test result.
c. Remind the client about safer sex practices.
d. Tell the client to be retested in 3 months.: ANS: A
The ELISA test can be falsely negative if testing occurs after the client
has become infected but prior to making antibodies to HIV. This period
of time is known as
the window period and can last up to 21 days. The confirmatory
3/
Medical-Surgical Nursing, 10th Edition
Ignatavicius:
1. 1. 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.: 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.
2. 2. 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: ANS: A
Anal intercourse is the riskiest sexual practice because the fragile anal
tissue can tear, creating a portal of entry for human immune
1/
, Chapter 17: Concepts of Care for Patients With HIV Disease
Medical-Surgical Nursing, 10th Edition
Ignatavicius:
deficiency virus in addition to providing mucus membrane contact with
the virus.
3. 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 (1 m) 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. Standard Precau- tions are required by the CDC. 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 (1 m) of the client is not
necessary with every client contact.
4. 4. A client with known HIV-II is admitted to the hospital with fever, night
sweats, and severe cough. Laboratory results include a CD4+ cell count of
180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What
action
2/
, Chapter 17: Concepts of Care for Patients With HIV Disease
Medical-Surgical Nursing, 10th Edition
Ignatavicius:
would the nurse take first?
a. Initiate Droplet Precautions for the client.
b. Notify the primary health care provider about the CD4+ results.
c. Place the client under Airborne Precautions.
d. Use Standard Precautions to provide care.: ANS: C
Since this client's CD4+ cell count is so low, he or she may have energy,
or the inability to mount an immune response to the TB test. The client
also appears to have progressed to HIV-III. The nurse would first place
the client on Airborne Precautions to prevent the spread of TB if it is
present. Next the nurse notifies the primary health care provider about
the low CD4+ count and requests alterative testing for TB. Droplet
Precautions are not used for TB. Standard Precautions are not adequate
in this case.
5. 5. A nurse is talking with a client about a negative enzyme-linked im-
munosorbent assay (ELISA) test for human immune deficiency virus (HIV).
The test is negative and the client states "Whew! I was really worried about
that result." What action by the nurse is most important? a. Assess the
client's sexual activity and patterns.
b. Express happiness over the test result.
c. Remind the client about safer sex practices.
d. Tell the client to be retested in 3 months.: ANS: A
The ELISA test can be falsely negative if testing occurs after the client
has become infected but prior to making antibodies to HIV. This period
of time is known as
the window period and can last up to 21 days. The confirmatory
3/
