A nurse in a community health clinic is caring for a client who has a history of HIV.
Which of the following assessment findings for the client would support that the client was in HIV stage 3 (AIDS)?
CD4 cell count of 250 (ref range 600-1500), and the client was diagnosed with pneumocystis pneumonia.
The client reports that their skin is dry.
The client reports flu-like symptoms.
CD4 cell count 210 cells/mm3 (ref range 600-1500)
The Correct Answer is A
A. CD4 cell count of 250 (ref range 600–1500), and the client was diagnosed with pneumocystis pneumonia — Correct. A CD4 count below 200 or the presence of an AIDS-defining condition like pneumocystis pneumonia qualifies as stage 3 HIV (AIDS). This client meets both criteria.
B. The client reports that their skin is dry — Dry skin is a nonspecific symptom and not diagnostic of stage 3 HIV.
C. The client reports flu-like symptoms — These are commonly seen in the early, acute phase of HIV infection—not in stage 3 (AIDS).
D. CD4 cell count 210 cells/mm³ (ref range 600–1500) — While this is low and approaching AIDS criteria, stage 3 is diagnosed at CD4 <200 or with an AIDS-defining illness. This count alone does not meet the full diagnostic criteria for stage 3 HIV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Peripheral edema is a sign of fluid retention and worsening heart failure, indicating that captopril (an ACE inhibitor) may not be effectively managing the client's condition.
B. A dry cough is a known side effect of ACE inhibitors like captopril, not a sign of treatment failure.
C. A skin rash can occur as a side effect but does not reflect the effectiveness of the drug in treating heart failure.
D. Postural hypotension is a common side effect, especially when starting ACE inhibitors, and is not an indicator that the therapy is ineffective.
Correct Answer is C
Explanation
A. While education on fluid restriction and daily weights is important for long-term management, it does not address the acute respiratory distress the patient is experiencing.
B. Synchronized cardioversion may be considered later for atrial fibrillation, but the immediate concern is respiratory compromise due to fluid overload, not arrhythmia alone.
C. Administering IV furosemide (a loop diuretic) is the priority intervention. The patient is showing signs of acute decompensated heart failure with pulmonary congestion (bibasilar crackles, dyspnea, oxygen saturation of 89%, weight gain). IV diuretics reduce preload and help relieve fluid overload, improving breathing and oxygenation.
D. Notifying the physician is appropriate, but not the first action. The nurse should act on existing orders (e.g., IV diuretics) to stabilize the patient’s condition before escalating.
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