Question

During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate? A. Administering an antibiotic B. Contacting the physician for an order for immune globulin C. Administering an antiviral D. Telling the client that he should remain in isolation for 2 weeks

Short answer

Answer: The most appropriate action for a nurse to take when a client with AIDS reports exposure to measles is to contact the physician for an order for immune globulin. This can help the client's immune system fight off the virus and potentially prevent or lessen the severity of the disease, especially considering their weakened immune system.

Step-by-step solution

Identify facts about the client and the problem

The client has AIDS, which means they have a weakened immune system. They have also been exposed to measles, which is a highly contagious viral disease.

Understand the available options

We have four possible actions to consider: A. Administer an antibiotic B. Contact the physician for an order for immune globulin C. Administer an antiviral D. Tell the client that they should remain in isolation for 2 weeks

Evaluate Option A - Antibiotics

Antibiotics are usually used to treat bacterial infections, not viral infections like measles. Although they may be helpful in treating secondary bacterial infections in some cases, antibiotics will not be effective in directly treating the measles virus.

Evaluate Option B - Immune Globulin

Immune globulin is a blood product containing antibodies. Administering immune globulin to someone who has been exposed to measles can help their immune system fight off the virus and potentially prevent or lessen the severity of the disease. This option could be especially beneficial for clients with weakened immune systems, like those with AIDS.

Evaluate Option C - Antivirals

Antiviral medications can be effective for treating viral infections. However, there is no specific antiviral medication approved for the treatment of measles. Additionally, the World Health Organization does not currently recommend antiviral therapy for measles.

Evaluate Option D - Isolation

Isolation for 2 weeks is a recommended measure for measles patients to prevent the spread of the disease, but it does not provide any preventive or treatment benefits to the person exposed to measles. While the client with AIDS might need to take extra precautions, isolation alone would not be an adequate response to their exposure.

Choose the most appropriate response

Based on the evaluations of the four options, contacting the physician for an order for immune globulin (Option B) is the most appropriate action. Immune globulin can offer preventative benefits and has a higher likelihood of being effective in this client's situation, given their weakened immune system.

Key concepts

Understand Disease Transmission

Disease transmission refers to the way infectious agents, such as viruses or bacteria, spread from one person to another. Knowing how diseases spread is crucial, especially for healthcare professionals who must protect themselves and their clients from infections. Measles, for example, is highly contagious and can spread through respiratory droplets from coughs or sneezes. Once a person is infected, they can easily pass the virus to others, even before symptoms appear.

A few ways diseases can spread include:

• Direct Contact: Touching an infected person or their bodily fluids.
• Indirect Contact: Touching surfaces or objects that have been contaminated.
• Airborne Transmission: Breathing in droplets or particles from the air.

Understanding these methods helps in implementing appropriate strategies to prevent further transmission and maintain health.

Immune System Functioning

The immune system is the body's defense against infections and illnesses. It detects harmful invaders, like viruses and bacteria, and works to fight them off. For individuals with conditions such as AIDS, the immune system is weakened. This means they have fewer defenses against infections and require special considerations.

The immune system consists of two main parts:

• Innate Immunity: The first line of defense, which includes barriers like skin and mucous membranes, and cells that quickly respond to invaders.
• Adaptive Immunity: A more specialized response that targets specific pathogens, involving antibodies and memory cells that "remember" past infections and respond more aggressively.

In cases of exposure to contagious diseases like measles, enhancing immune response through methods like immune globulin injections can provide added protection, especially for those with compromised immunity.

Nursing Interventions for Viral Exposure

Nursing interventions involve actions taken by nurses to address and manage patients' health needs. When a client with AIDS is exposed to a virus like measles, nurses must implement specific strategies to protect and support the client.

Key interventions may include:

• Administering immune globulin to boost the immune response to the virus, especially important in patients with weakened immunity.
• Educating patients about the nature of their exposure and providing guidance on symptom monitoring and management at home.
• Coordinating care with physicians and healthcare teams to ensure timely and appropriate treatment measures are taken.

A strategic intervention plan helps minimize the risk of disease progression and increased infection complications.

Client Assessment and Evaluation

Client assessment involves collecting information about a person's health status to inform care decisions. For someone exposed to a contagious disease like measles, especially with a vulnerable immune system, thorough evaluation is necessary.

Steps in assessment and evaluation include:

• Gathering detailed health history, including any previous exposure to infectious diseases and current symptoms.
• Monitoring vital signs and physical symptoms regularly to catch any early signs of infection or complications.
• Communicating with the client about any new symptoms or concerns, ensuring they receive appropriate diagnostic tests if needed.

Effective assessment allows for tailored care plans and timely interventions, improving patient outcomes and managing exposure risks efficiently.