1. A client is receiving antipsychotic medication in a hospital setting. The nurse understands it is considered an emergency if the client experiences any of the following symptoms: dyspnea or tachypnea, tachycardia, fever, high or low blood pressure, increased sweating, loss of bladder control, or seizures. The nurse understands the following nursing actions are required:
a. Administer anti-seizure medication stat
b. Notify the physician immediately
c. Place the patient in the Trendelenburg position
d. Monitor Intake and Output
2. After washing his/her hands, a nurse uses a paper towel to turn off the faucet. What is the reason for the nurse to turn the faucet off in this way?
a. To protect the sterility of his/her hands
b. To keep the faucet handle clean and germ free
c. To prevent the hands from becoming contaminated with microorganisms from the handle.
d. To prevent the faucet from becoming contaminated with microorganisms from the hands.
3. A nurse is caring for a HIV-positive patient in the hospital. The nurse understands the difference between infectious diseases and contagious diseases. The nurse understands what characteristics about the infection in someone who is HIV-positive?
a. It is both infectious and contagious
b. It is only considered an infectious disease
c. It is only considered a contagious disease
d. It is neither infectious nor contagious
4. The nurse understands that some viruses are difficult to spread and that others are easy to spread. The efficiency with which a virus is transmitted depends on the number of viruses a person is exposed to or the inoculum size. With this information, the nurse understands that:
a. HIV is transmitted like other common infectious diseases
b. HIV has a certain efficiency of transmission and a certain incubation period.
c. HIV is transmitted efficiently
d. HIV has a very short incubation period
5. The nurse understands about the sources of HIV infection. Given this understanding the nurse knows that:
a. A person with HIV infection is never the sole source of the infection.
b. Any person with HIV infection, regardless of symptoms is capable of transmitting the disease.
c. Only a person with active HIV infection is capable of transmitting the disease.
d. All persons whether infected with HIV or not are capable of transmitting the disease.
6. The nurse understands that the numbers of HIV are greatest in what type/s of body fluid?
a. women’s genital secretions and breast milk
b. semen and breast milk
c. blood and saliva
d. semen and tears
7. The nurse understands that a variety of casual contact methods pose no risk of transmitting the virus. These include all EXCEPT the following types of contact:
a. sharing a toilet, closed-mouth kissing
b. sharing eating utensils, hugging
c. being sneezed on, drinking from the same glass
d. breastfeeding by an infected mother, breastfeeding by an infected baby
8. The nurse caring for the HIV positive patient understands that ___________ is the most important way to prevent the spread of most infectious microbes, not just HIV.
a. wearing a face mask
b. wearing gloves
c. using handwashing
d. infection precautions
9. The nurse understands that patients who are HIV positive are susceptible to infections by a host of other microbes. These infections are called opportunistic infections. Some of the MOST common of these types of infections particularly in the HIV positive patient include:
a. thrush and rhinovirus
b. Pneumocystis pneumonia and influenza
c. toxoplasmosis and cytomegalovirus
d. tuberculosis and Herpes Zoster
10. The nurse who is caring for the HIV positive patient has taken all the necessary precautions. In spite of that fact she accidentally stuck her finger with a needle which was used to give pain medication to the patient. What should be the nurse’s FIRST action?
a. Contact her head nurse and report the incident
b. Visit the employee health nurse to have the appropriate blood samples drawn
c. Wash her hands with soapy, warm water.
d. Place the needle in a container to take to the employee health nurse
Answers and Explanations
1. B: Explanation: Notify the physician immediately The physician should be notified immediately as this could be a sign of neuroleptic malignant syndrome. This could potentially become fatal to the patient if not addressed immediately. The nurse should notify the physician, monitor vital signs, initiate safety and seizure precautions, discontinue the medication, monitor the patient’s level of consciousness, and provide nursing interventions for fever (if present).
2. C: Explanation: To prevent the hands from becoming contaminated with microorganisms from the handle. - 70 - By using a towel to turn off the faucet, the nurse will prevent her now clean hands from being contaminated by microorganisms which will be on the handle after she turned the faucet on before her hands were clean. The hands would not be considered sterile after simply washing them with soap and water.
3. A: Explanation: It is both infectious and contagious Infectious diseases are caused by microbes; HIV is caused by a virus which is a microbe. Contagious diseases are spread often from person to person. There are some diseases which are infectious but not contagious. HIV is both infectious and contagious.
4. B: Explanation: HIV has a certain efficiency of transmission and a certain incubation period HIV is not transmitted like other common infectious diseases. The types of contact for transmission are very specific, transmission is very inefficient and HIV’s incubation period is very long.
5. B: Explanation: Any person with HIV infection, regardless of symptoms is capable of transmitting the disease. Even the person who has HIV infection and is asymptomatic is capable of transmitting the disease. A person with HIV infection is almost always the sole source of this infection. The only time a person is not directly involved would be in the case of a laboratory worker who has not taken the appropriate precautions and is infected while working with large numbers of the virus while doing research.
6. B: Explanation: semen and breast milk The numbers of Human Immunodeficiency Virus are greatest in semen, breast milk, and blood (including menstrual blood). The numbers of HIV are fewer in women’s genital secretions. It is unlikely to be in saliva, stool, and tears.
7. D: Explanation: breastfeeding by an infected mother, breastfeeding by an infected baby This type of contact is not casual contact in nature. It should be noted that this type of contact rarely results in transmission of HIV but is possible.
8. C: Explanation: using handwashing Handwashing is the best way for the health care worker to prevent the spread of microbes.
9. C: Explanation: toxoplasmosis and cytomegalovirus These are particular opportunistic infections which are common in the HIV positive individual. Other common opportunistic infections include: pneumocystis pneumonia, mycobacterium avium complex and thrush. People with HIV infection usually do not develop these complications or opportunistic infections until - 71 - relatively late in the disease after their immune systems are impaired more profoundly. These infections are normally not transmitted to the health care giver. The exception would be if the HIV positive individual developed mycobacterium tuberculosis.
10. C: Explanation: Wash her hands with soapy, warm water. This would be a case of setting priorities. The nurse would first want to wash her hands with warm, soapy water to limit further exposure. The next step would be to notify a superior and perform and incident report and visit the employee health nurse to allow the appropriate blood samples to be drawn and proper precautions taken. It is not necessary to save the needle. It should be disposed of in a proper disposal container immediately.