Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

Choice A reason: Inflammation is not an example of a client's primary defense to infection. Inflammation is a secondary defense to infection, which is activated after the primary defense has been breached. Inflammation is a complex process that involves the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of exudate. Inflammation aims to contain, neutralize, and eliminate the infectious agent and to repair the damaged tissue.

Choice B reason: Fever is not an example of a client's primary defense to infection. Fever is a secondary defense to infection, which is activated after the primary defense has been breached. Fever is an elevation of the body temperature above the normal range, which is usually 36.5 to 37.5 degrees Celsius or 97.7 to 99.5 degrees Fahrenheit. Fever is a systemic response to infection that is regulated by the hypothalamus, which is the part of the brain that controls the body's thermostat. Fever enhances the immune system's activity and inhibits the growth of some pathogens.

Choice C reason: Phagocytosis is not an example of a client's primary defense to infection. Phagocytosis is a secondary defense to infection, which is activated after the primary defense has been breached. Phagocytosis is a process that involves the engulfment and destruction of foreign particles, such as bacteria, by specialized cells, such as macrophages and neutrophils. Phagocytosis is a type of cellular immunity that eliminates the infectious agent and prevents its spread.

Choice D reason: Intact skin is an example of a client's primary defense to infection. Intact skin is the first and most important line of defense against infection, as it forms a physical barrier that prevents the entry of pathogens into the body. Intact skin also has chemical and biological properties that resist infection, such as the acidic pH, the secretion of sebum and sweat, and the presence of normal flora. Intact skin protects the underlying tissues and organs from infection and injury.

Choice A reason: Washing your hands thoroughly is an important measure to reduce the risk of infection. Hand washing is one of the most effective ways to prevent the transmission of germs that can cause diseases. Hand washing can remove dirt, bacteria, viruses, and other contaminants from the skin and prevent them from entering the body or spreading to others. The nurse should teach the client with AIDS to wash their hands frequently and properly, especially before and after eating, using the bathroom, touching their face, or handling any objects that may be contaminated.

Choice B reason: Avoiding cleaning your toothbrush with bleach is not a measure to reduce the risk of infection. Cleaning your toothbrush with bleach is not a recommended practice, as bleach is a harsh chemical that can damage the toothbrush and irritate the mouth. However, cleaning your toothbrush with bleach does not increase the risk of infection, as bleach can kill most germs that may be present on the toothbrush. The nurse should teach the client with AIDS to rinse their toothbrush with water after each use and replace it every 3 to 4 months or sooner if the bristles are worn or frayed.

Choice C reason: Avoiding raw fruits and vegetables is a measure to reduce the risk of infection. Raw fruits and vegetables may be contaminated with bacteria, parasites, or pesticides that can cause foodborne illnesses. The client with AIDS has a weakened immune system that cannot fight off these infections effectively and may develop serious complications, such as diarrhea, dehydration, or malnutrition. The nurse should teach the client with AIDS to wash, peel, or cook their fruits and vegetables before eating them and to avoid any that are bruised, moldy, or spoiled.

Choice D reason: Avoiding crowds is a measure to reduce the risk of infection. Crowds are places where many people gather and interact, such as public transportation, shopping malls, schools, or workplaces. Crowds increase the exposure to germs that can cause respiratory, gastrointestinal, or skin infections. The client with AIDS has a lowered resistance to these infections and may contract them more easily and severely. The nurse should teach the client with AIDS to avoid crowds as much as possible and to wear a mask, practice social distancing, and use hand sanitizer if they have to be in a crowded place.

Choice E reason: Not sharing toothpaste with family members is a measure to reduce the risk of infection. Sharing toothpaste with family members can transfer saliva, blood, or other body fluids that may contain germs that can cause oral, dental, or systemic infections. The client with AIDS is more susceptible to these infections and may also transmit the HIV virus to their family members through their body fluids. The nurse should teach the client with AIDS to use their own toothpaste and toothbrush and to store them separately from their family members' ones.