What can the nurse teach the client with acquired immunodeficiency syndrome (AIDS) to reduce the risk of infection? (Select all that apply.)

Choice A reason: This is not the priority assessment because peripheral edema is not a lifethreatening complication of immobility. Peripheral edema is the swelling of the lower extremities due to fluid accumulation. It can be caused by various factors, such as venous insufficiency, heart failure, kidney disease, or medication side effects. The nurse should monitor the client's fluid status and provide elevation and compression therapy as needed.

Choice B reason: This is the priority assessment because lung sounds can indicate the presence of respiratory complications, such as pneumonia or atelectasis, which are common and serious consequences of immobility. Pneumonia is an infection of the lungs that causes inflammation, mucus production, and impaired gas exchange. Atelectasis is the collapse of alveoli, which are the tiny air sacs in the lungs that facilitate oxygen and carbon dioxide exchange. The nurse should auscultate the client's lung sounds regularly and report any abnormal findings, such as crackles, wheezes, or diminished breath sounds. The nurse should also encourage the client to cough, deep breathe, and use incentive spirometry to prevent or treat respiratory problems.

Choice C reason: This is not the priority assessment because bowel sounds can reflect the status of the gastrointestinal system, which is not directly affected by immobility. Bowel sounds are the noises produced by the movement of food and gas through the intestines. They can vary in frequency and intensity depending on the client's diet, activity, and medications. The nurse should auscultate the client's bowel sounds and assess for any signs of constipation, diarrhea, or obstruction. The nurse should also promote the client's bowel function by providing adequate hydration, fiber, and laxatives as ordered.

Choice D reason: This is not the priority assessment because skin turgor can indicate the level of hydration, which is not a primary concern of immobility. Skin turgor is the elasticity of the skin that allows it to return to its normal shape after being pinched or pulled. It can be affected by factors such as age, weight loss, dehydration, or edema. The nurse should assess the client's skin turgor and provide adequate fluids and electrolytes as needed. The nurse should also pay attention to the client's skin integrity and prevent or treat any pressure ulcers or wounds that may result from immobility.

Choice A reason: Popping bursae from standing is not the cause of the grating sound. Bursae are fluidfilled sacs that cushion the joints and reduce friction. Popping bursae may produce a snapping or clicking sound, but not a grating sound.

Choice B reason: A herniated disk in the diseased joint is not the cause of the grating sound. A herniated disk is a condition where the soft inner part of the intervertebral disk bulges out through a tear in the outer layer. A herniated disk may cause pain, numbness, or weakness, but not a grating sound.

Choice C reason: Pieces of bone and cartilage floating is the cause of the grating sound. Osteoarthritis is a degenerative joint disease that causes the breakdown of the cartilage and bone in the joints. Pieces of bone and cartilage may detach and float in the joint space, causing a grating sound when the joint moves.

Choice D reason: Years of an autoimmune process is not the cause of the grating sound. An autoimmune process is a condition where the immune system attacks the body's own tissues. An autoimmune process may cause inflammation, swelling, or damage to the joints, but not a grating sound.