A client has acquired immunodeficiency syndrome (AIDS). Which of these assessment findings indicate possible 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: Once the tissue has necrosed from high pressure, it does not regenerate is the best explanation, because it describes the mechanism and outcome of glaucoma. Glaucoma is a condition that causes increased intraocular pressure, which damages the optic nerve and the retina, the tissues that are responsible for transmitting and processing visual information. Once these tissues are necrosed, or dead, they do not regenerate, or grow back, resulting in irreversible vision loss.

Choice B reason: Glaucoma always leads to permanent blindness is not a good explanation, because it is inaccurate and pessimistic. Glaucoma does not always lead to permanent blindness, but rather to progressive vision loss that can be prevented or slowed down with early diagnosis and treatment. Glaucoma can cause peripheral vision loss, tunnel vision, or blind spots, but not necessarily complete blindness.

Choice C reason: Once retinal detachment occurs, it does not return to its normal state is not a good explanation, because it is irrelevant and misleading. Retinal detachment is a condition that occurs when the retina separates from the underlying layer of blood vessels, which can cause vision loss or blindness. However, retinal detachment is not caused by glaucoma, nor is it a common complication of glaucoma. Retinal detachment can sometimes be repaired with surgery, depending on the extent and duration of the detachment.

Choice D reason: Once bacterial infection has caused damage, the tissue does not regenerate is not a good explanation, because it is incorrect and confusing. Bacterial infection is not a cause or a consequence of glaucoma, but rather a separate condition that can affect the eye. Bacterial infection can cause inflammation, pain, discharge, or redness in the eye, but not necessarily vision loss or tissue necrosis. Bacterial infection can usually be treated with antibiotics, which can prevent or reverse the damage.