HIVAIDS NCLEX Questions

HIV/AIDS NCLEX Questions Jackie_Lambert3 Save

EX4: ch 19 HIV/AIDS NCLEX Practice...

53 terms palmerdjphPreview Lupus NCLEX questions 18 terms janeth_rodriguez21 Preview

Med-Surg CH 35: HIV/AIDS, Study G...

35 terms rcs11Preview

STD NC

52 terms sar A patient who has tested positive for the human immunodeficiency virus (HIV) arrives at the clinic with a report of fever, nonproductive cough, and fatigue. The patient's CD4 count is 184 cells/mcL. How should the healthcare provider interpret these findings?Please choose from one of the following options.

• The patient is diagnosed with acquired immunodeficiency syndrome (AIDS).

B.The patient is now in the latent stages of HIV infection C.These findings provide evidence that the patient has seroconverted.

• This is an expected finding because the patient has tested positive for HIV.

The patient is diagnosed with acquired immunodeficiency syndrome (AIDS).Which member of the health care team demonstrates reducing the risk for infection for the client with acquired immunodeficiency syndrome

(AIDS)?

• The dietary worker hands the disposable meal trays to the LPN assigned to the client.
• The social worker encourages the client to verbalize about stressors at home.
• Housekeeping thoroughly cleans and disinfects the hallways near the client's room.
• Health care provider orders vital signs including temperature every 8 hours.

(A)

• The dietary worker hands the disposable meal trays to the LPN assigned to the client.

Rationale: This limits the number of health care personnel entering the room.

Incorrect:

• The social worker encourages the client to verbalize about stressors at home.

Rationale: Verbalizing stressors does not reduce the risk for infection.

• Housekeeping thoroughly cleans and disinfects the hallways near the client's room.

Rationale: Bathrooms, not hallways, that are cleaned at least once daily by housekeeping reduces infection. D) Health care provider orders vital signs including temperature every 8 hours.Rationale Vital signs, including temperature, should be taken every 4 hours to detect potential infection.

The nurse is instructing an unlicensed health care worker on the care of the client with HIV who also has active genital herpes. Which statement by the health care worker indicates effective teaching of standard precautions?

• ''I need to know my HIV status, so I must get tested before caring for any clients."
• ''Putting on a gown and gloves will cover up the itchy sores on my elbows.''
• ''Washing my hands and putting on a gown and gloves is what I must do before starting care.''
• ''I will wash my hands before going into the room, and then put on gown and gloves only for direct contact with the client's genitals."

(C)

• ''Washing my hands and putting on a gown and gloves is what I must do before starting care.''

Rationale: Standard precautions include whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes.

Incorrect:

• ''I need to know my HIV status, so I must get tested before caring for any clients."

Rationale: Knowing HIV status is important for preventing transmission of HIV, but is not a standard precaution.

• ''Putting on a gown and gloves will cover up the itchy sores on my elbows.''

Rationale: Health care workers with weeping dermatitis should not provide direct client care regardless of the use of gown and gloves.

• ''I will wash my hands before going into the room, and then put on gown and gloves only for direct contact with the client's genitals."

Rationale: Unlicensed health care workers cannot make the determination of what is required for PPE or standard precaution Which statement made to the nurse by a health care worker assigned to care for the client with HIV indicates a breach of confidentiality and requires further education by the nurse?

• ''I told the family members they needed to wash their hands when they enter and leave the room.''
• ''The other health care worker and I were out in the hallway discussing how we were concerned about getting HIV from our client, so no one

could hear us in the client's room.''

• ''Yes, I understand the reasons why I have to wear gloves when I bathe my client.''
• ''The client's spouse told me she got HIV from a blood transfusion.

(B)

• ''The other health care worker and I were out in the hallway discussing how we were concerned about getting HIV from our client, so no one

could hear us in the client's room.'' Rationale: Discussing this client's illness outside the client's room is a breach of confidentiality.

Incorrect:

• ''I told the family members they needed to wash their hands when they enter and leave the room.'' Rationale: Instruction on handwashing to

family members or friends is not a breach of confidentiality. C) ''Yes, I understand the reasons why I have to wear gloves when I bathe my client.'' Rationale: This recognizes standard precautions in direct care, and is not a breach of confidentiality.

• ''The client's spouse told me she got HIV from a blood transfusion.''

Rationale: The health care worker assigned is relaying the conversation to the nurse. This is not a breach of confidentiality

When preparing the newly diagnosed client with HIV and significant other for discharge, which explanation by the nurse accurately describes proper condom use?

• ''Condoms should be used when lesions on the penis are present.''
• ''Always position the condom with a space at the tip of an erect penis.''
• ''Make sure it fits loosely to allow for penile erection.''
• ''Use adequate lubrication such as petroleum jelly.''

B)

• ''Always position the condom with a space at the tip of an erect penis.''

Rationale: This allows for the collection of semen at the tip of the condom.

Incorrect:

• ''Condoms should be used when lesions on the penis are present.''

Rationale: Condoms must be used at all times with sexual activity, with or without the presence of lesions.

• ''Make sure it fits loosely to allow for penile erection.''

Rationale: Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip.

• ''Use adequate lubrication such as petroleum jelly.''

Rationale: Lubricants should be water-based only.

The nurse presents a seminar on HIV testing to a group of seniors and their caregivers in an assisted living facility. Which responses fit the Centers for Disease Control and Prevention's (CDC's) recommendations for HIV testing? (Select all that apply.)

• ''I am 78 years old and I was treated and cured of syphilis many years ago.''
• ''In 1986, I received a transfusion of platelets.''
• ''Seven years ago, I was released from a penitentiary.''
• ''I used to smoke marijuana 30 years ago, but I have not done any drugs since.''
• ''I had sex with a man with a disreputable past from New York back in the late 1960s, but I have been happily married since 1971.''
• ''At 68, I am going to get married for the fourth time.''
• ''Downtown was where I picked up the best hookers back in the 1950s.'

-(A, C, F)

• ''I am 78 years old and I was treated and cured of syphilis many years ago.''

Rationale: People who have had sexually transmitted diseases should be tested for HIV.

• ''Seven years ago, I was released from a penitentiary.''

Rationale: HIV testing is recommended for people who are or have been in jails or prisons.

• ''At 68, I am going to get married for the fourth time.''

Rationale: People who are planning to get married should be tested for HIV.

Incorrect:

• ''In 1986, I received a transfusion of platelets.''

Rationale: People who received blood transfusions between 1978 and 1985 should be tested for HIV.

• ''I used to smoke marijuana 30 years ago, but I have not done any drugs since.''

Rationale: HIV testing is recommended only for injection drug users.

• ''I had sex with a man with a disreputable past from New York back in the late 1960s, but I have been happily married since 1971.''

Rationale: AIDS cases were extremely rare prior to the 1970s.

• ''Downtown was where I picked up the best hookers back in the 1950s.''

Rationale: The current AIDS pandemic started in the mid to late 1970s.

Which interventions does the home health nurse teach to family members to reduce confusion in the client diagnosed with AIDS dementia?(Select all that apply.)

• Report any behavior changes.
• Use the Glasgow Coma Scale on a daily basis.
• Change the decorations in the home according to the season.
• Put the bed close to the window.
• Write out all instructions and have the client read them over before performing a task.
• Ask the client when he or she wants to shower or bathe.
• Mark off the days of the calendar, leaving open the current date.
• For continuity, the primary caregiver should be the only person reorienting the client.

-(C, D, F, G)

• Change the decorations in the home according to the season.

Rationale: Seasonal decorations in the home helps with maintaining orientation.

• Put the bed close to the window.

Rationale: This allows the client to visualize seasonal and weather changes and assists in orientation.

• Ask the client when he or she wants to shower or bathe.

Rationale: Involving the client in planning the daily schedule helps with orientation.

• Mark off the days of the calendar, leaving open the current date.

Rationale: Using calendars and crossing off past dates helps with orientation.

Incorrect:

• Report any behavior changes.

Rationale: This does not reduce confusion.

• Use the Glasgow Coma Scale on a daily basis.

Rationale: This assessment tool is used by the home health nurse.

• Write out all instructions and have the client read them over before performing a task.

Rationale: Instructions should be kept short, simple, and verbal.

• For continuity, the primary caregiver should be the only person reorienting the client.

Rationale: Everyone caring for the client should be involved in reorientation methods.The home health nurse is making an initial home visit to the client currently living with family members after being hospitalized with pneumonia and newly diagnosed with AIDS. Which statement by the nurse best acknowledges the client's fear of discovery by his family?

• ''Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?''
• ''Is there somewhere private in the home we can go and talk?''
• ''I hope that all of your family members know about your disease and how you need to be protected, since you have been so sick.''
• ''It is your duty to protect your family members from getting AIDS.''

(B)

• ''Is there somewhere private in the home we can go and talk?''

Rationale: A nonthreatening approach initially to find out whether the client has informed family members or desires privacy is very important.

Incorrect:

• ''Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?''

Rationale: The client has a right to privacy and can make the decision whether to post handwashing signs. Caution signs invade the client's right to privacy.

• ''I hope that all of your family members know about your disease and how you need to be protected, since you have been so sick.''

Rationale: Protection from infection is important, but this approach is not respectful of the client's right to privacy.

• ''It is your duty to protect your family members from getting AIDS.''

Rationale: This statement by the nurse is rather intimidating. It is the client's right whether he wants to make the decision to inform or not inform family members about their illness. However, this ''nonaction'' could be grounds for a lawsuit if the client were to infect someone inadvertently.