Chapter 17: Concepts of Care for Patients
with HIV Disease
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client with HIV-III and wasting syndrome has inadequate nutrition. What
assessment finding by the nurse best indicates that goals have been met for this client
problem?
a. Chooses high-protein food.
b. Has decreased oral discomfort.
c. Eats 90% of meals and snacks.
d. Has a weight gain of 2 lb (1 kg)/1 mo.
ANS: D
The weight gain is the best indicator that goals for this client problem have been met
because it demonstrates that the client not only is eating well but also is able to absorb
the nutrients. Choosing high-protein food is important, but only if the client eats and
absorbs the nutrients.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation
KEY: HIV disease, Nutrition MSC: Client Needs Category:
Physiological Integrity: Basic Care and Comfort
2. A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The
nurse dresses them with sterile gauze. When changing these dressings, which action is
most important for the nurse’s safety?
a. Adhering to Standard Precautions
, b. Assessing tolerance to dressing changes
c. Performing hand hygiene before and after care
d. Disposing of soiled dressings properly
ANS: A
All of the actions are important, but due to the infectious nature of this illness, the
nurse would ensure he or she is following Standard Precautions (and Transmission-
Based Precautions when necessary) to avoid a potential exposure.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: HIV disease, Standard precautions MSC: Client Needs
Category: Safe and Effective Care Environment: Safety and Infection Control
3. A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection.
Which action by the nurse is most appropriate?
a. Initiate Contact Precautions.
b. Conduct frequent neurologic assessments.
c. Conduct frequent respiratory assessments.
d. Initiate Protective Precautions.
ANS: D
Toxoplasma gondii infection is an opportunistic infection that causes an encephalitis
but poses only a rare threat to immunocompetent individuals The nurse would
perform ongoing neurologic assessments. Contact and Protective Precautions are not
needed. Good respiratory assessments are important to the client, but toxoplasmosis
will demonstrate neurologic signs and symptoms.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: HIV disease, Nursing assessment MSC:
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
, 4. A client has just been informed of a positive HIV test. The client is distraught and
does not know what to do. What intervention by the nurse is best?
a. Assess the client for support systems.
b. Determine if a clergy member would help.
c. Explain legal requirements to tell sex partners.
d. Offer to tell the family for the client.
ANS: A
This client needs the assistance of support systems. The nurse would help the client
identify them and what role they can play in supporting him or her. A clergy member
may or may not be welcome. Positive HIV test results are reportable in all 50 states,
Washington, D.C., and Canada but the nurse works with the client to support his or
her choices in disclosure. The nurse would not tell the family for the client.
DIF: Applying TOP: Integrated Process: Caring KEY: HIV
disease, Psychosocial response MSC: Client Needs Category:
Psychosocial Integrity
5. A nurse is caring for a client with HIV-III who was admitted with HAND. What sign
or symptom would be most important for the nurse to report to the primary health care
provider?
a. Nausea
b. Change in pupil size
c. Weeping open lesions
d. Cough
ANS: B
HIV-associated neurocognitive disorder (HAND) is a sign of neurologic involvement.
The nurse would report any sign of increasing intracranial pressure immediately,
including change in pupil size, level of consciousness, vital signs, or limb strength.
The other signs and symptoms are not life threatening and would be documented and
reported appropriately.
with HIV Disease
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client with HIV-III and wasting syndrome has inadequate nutrition. What
assessment finding by the nurse best indicates that goals have been met for this client
problem?
a. Chooses high-protein food.
b. Has decreased oral discomfort.
c. Eats 90% of meals and snacks.
d. Has a weight gain of 2 lb (1 kg)/1 mo.
ANS: D
The weight gain is the best indicator that goals for this client problem have been met
because it demonstrates that the client not only is eating well but also is able to absorb
the nutrients. Choosing high-protein food is important, but only if the client eats and
absorbs the nutrients.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation
KEY: HIV disease, Nutrition MSC: Client Needs Category:
Physiological Integrity: Basic Care and Comfort
2. A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The
nurse dresses them with sterile gauze. When changing these dressings, which action is
most important for the nurse’s safety?
a. Adhering to Standard Precautions
, b. Assessing tolerance to dressing changes
c. Performing hand hygiene before and after care
d. Disposing of soiled dressings properly
ANS: A
All of the actions are important, but due to the infectious nature of this illness, the
nurse would ensure he or she is following Standard Precautions (and Transmission-
Based Precautions when necessary) to avoid a potential exposure.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: HIV disease, Standard precautions MSC: Client Needs
Category: Safe and Effective Care Environment: Safety and Infection Control
3. A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection.
Which action by the nurse is most appropriate?
a. Initiate Contact Precautions.
b. Conduct frequent neurologic assessments.
c. Conduct frequent respiratory assessments.
d. Initiate Protective Precautions.
ANS: D
Toxoplasma gondii infection is an opportunistic infection that causes an encephalitis
but poses only a rare threat to immunocompetent individuals The nurse would
perform ongoing neurologic assessments. Contact and Protective Precautions are not
needed. Good respiratory assessments are important to the client, but toxoplasmosis
will demonstrate neurologic signs and symptoms.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: HIV disease, Nursing assessment MSC:
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
, 4. A client has just been informed of a positive HIV test. The client is distraught and
does not know what to do. What intervention by the nurse is best?
a. Assess the client for support systems.
b. Determine if a clergy member would help.
c. Explain legal requirements to tell sex partners.
d. Offer to tell the family for the client.
ANS: A
This client needs the assistance of support systems. The nurse would help the client
identify them and what role they can play in supporting him or her. A clergy member
may or may not be welcome. Positive HIV test results are reportable in all 50 states,
Washington, D.C., and Canada but the nurse works with the client to support his or
her choices in disclosure. The nurse would not tell the family for the client.
DIF: Applying TOP: Integrated Process: Caring KEY: HIV
disease, Psychosocial response MSC: Client Needs Category:
Psychosocial Integrity
5. A nurse is caring for a client with HIV-III who was admitted with HAND. What sign
or symptom would be most important for the nurse to report to the primary health care
provider?
a. Nausea
b. Change in pupil size
c. Weeping open lesions
d. Cough
ANS: B
HIV-associated neurocognitive disorder (HAND) is a sign of neurologic involvement.
The nurse would report any sign of increasing intracranial pressure immediately,
including change in pupil size, level of consciousness, vital signs, or limb strength.
The other signs and symptoms are not life threatening and would be documented and
reported appropriately.
