HIV: Know the Risks
A client asks whether HIV can be transmitted through everyday physical contact with family members. What should guide the nurse’s teaching?
HIV is not spread through casual contact such as hugging, touching, or sharing normal household activities.
A client with SLE asks how to manage chronic fatigue while remaining active. What general approach should the nurse recommend?
Balance activity with planned periods of rest.
A client with a known latex allergy may also react to certain foods. Name one food commonly associated with this cross-sensitivity.
Banana, avocado, kiwi, or another recognized latex-associated food.
A client has experienced several days of severe diarrhea. Which electrolyte should receive particular attention?
Potassium.
Which types of tasks are usually appropriate to delegate to UAP: assessment and teaching, or routine hygiene and comfort measures?
Routine hygiene and comfort measures.
A client taking antiretroviral medications says, “I feel fine now, so missing a dose once in a while shouldn’t matter.” What concern should the nurse have?
Medication nonadherence can allow viral replication and contribute to drug resistance.
A client with SLE is planning an outdoor vacation. What environmental exposure should the nurse discuss?
Ultraviolet/sun exposure because it may trigger or worsen an SLE flare.
Minutes after receiving a medication, a client develops widespread hives and wheezing. Which body system becomes the immediate priority?
Airway/respiratory system.
A client has a platelet count that is dramatically below normal. Which complication should the nurse focus on preventing?
Bleeding/hemorrhage.
A severely neutropenic client receives visitors. What should the nurse consider before allowing visitors into the room?
Whether visitors have fever or signs of infection.
A client with advanced HIV develops fever, dry cough, increasing dyspnea, and hypoxemia. Which type of complication should move to the top of the nurse’s concern list?
An opportunistic respiratory infection, particularly PJP.
A client taking hydroxychloroquine asks why another specialist has been added to the healthcare team. Which specialist is especially important?
An ophthalmologist because of the risk for retinal toxicity.
A client develops swelling of the lips and tongue after starting a new medication. What complication should the nurse suspect?
Angioedema.
A severely immunocompromised client has an extremely low absolute neutrophil count. What is the major immediate risk?
Serious infection.
A client receiving immunosuppressive therapy develops a fever. Why should this finding receive prompt attention?
Immunosuppression increases infection risk, and fever may indicate a serious infection.
When evaluating whether HIV treatment is working, which type of information is more useful: improvement in appetite or laboratory evidence of viral suppression?
Laboratory evidence of viral suppression/viral load.
A client with SLE develops hypertension, edema, protein in the urine, and decreasing urine output. Which complication should the nurse suspect?
Lupus nephritis.
A client uses an epinephrine autoinjector for a severe allergic reaction and says the symptoms are gone. What should happen next?
The client should still seek emergency medical care because symptoms may recur.
A client’s ECG shows prominent U waves after several days of gastrointestinal losses. Which electrolyte disturbance should the nurse suspect?
Hypokalemia.
An RN has already assessed a client experiencing a severe allergic reaction. Which type of intervention may potentially be delegated to an LPN/LVN according to facility policy?
Administration of a prescribed medication after the RN has assessed the client and established the plan of care.
A client with severe immune suppression develops sudden confusion and a severe headache. Why should the nurse treat this differently from oral soreness or decreased appetite?
Acute neurologic changes may indicate a serious opportunistic CNS infection and require immediate evaluation.
A client who has been taking corticosteroids for an extended period reports weakness, dizziness, and unusual salt cravings. What medication question should the nurse ask immediately?
Whether the client recently stopped or abruptly reduced the corticosteroid.
During a medication infusion, a client suddenly develops wheezing, hypotension, swelling, and urticaria. Identify the general sequence of nursing priorities.
Stop exposure to the allergen, support airway/breathing/circulation, administer emergency treatment such as epinephrine as prescribed, and closely monitor.
ABGs show a decreased pH, increased PaCO₂, and a bicarbonate level that has not significantly changed. What acid-base disorder is present?
Acute respiratory acidosis.
Four clients need assessment: one has chronic joint discomfort, one has oral candidiasis, one needs routine teaching, and one has severe neutropenia with a fever. Who goes first?
The client with severe neutropenia and fever because of the risk for rapidly progressing infection/sepsis.