A homeless client arrives in the emergency room. The client verbalizes an inability to bathe for at least one month. What is the nurse's priority?

Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.

Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.

Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.

Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.

Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.

Choice A reason: "I will monitor my nutrition and fluid status." is not a statement that requires further teaching or clarification, because it is correct and appropriate. Monitoring nutrition and fluid status is an important selfcare measure for people with HIV, as it can help maintain the immune function, prevent dehydration, and promote healing. People with HIV should eat a balanced and varied diet, drink enough water, and avoid foods or drinks that can cause diarrhea, nausea, or vomiting.

Choice B reason: "Because I have HIV, that means I'm an AIDS patient." is a statement that requires further teaching or clarification, because it is incorrect and misleading. Having HIV does not mean that one has AIDS, but rather that one is at risk of developing AIDS. HIV is the virus that causes AIDS, which is the most advanced stage of the infection. AIDS is diagnosed when the CD4+ Tcell count drops below 200 cells per microliter of blood, or when the person develops one or more opportunistic infections or cancers. People with HIV can delay or prevent the progression to AIDS by taking antiretroviral drugs, which can suppress the viral load and improve the immune function.

Choice C reason: "I can still have unprotected intercourse with my partner since he doesn't have HIV." is a statement that requires further teaching or clarification, because it is incorrect and misleading. Having unprotected intercourse with a partner who does not have HIV is not safe or advisable, as it can expose the partner to the risk of contracting HIV. HIV is transmitted through sexual contact, as well as through blood, semen, vaginal fluid, or breast milk. People with HIV should use condoms or other barrier methods during intercourse, regardless of the HIV status of their partner. People with HIV should also inform their partner about their infection, and encourage them to get tested and treated if needed.

Choice D reason: "I need to ensure that I place my needles in a proper needle disposal container." is not a statement that requires further teaching or clarification, because it is correct and appropriate. Placing needles in a proper needle disposal container is an important infection prevention measure for people with HIV, as it can prevent the accidental or intentional reuse or sharing of needles, which can transmit HIV or other bloodborne diseases. People with HIV should use new and sterile needles for injections, and dispose of them in a punctureresistant and leakproof container, which can be obtained from a pharmacy, clinic, or health department.

Choice E reason: "I can spread this through contact with surfaces, so I need to wear gloves in public." is a statement that requires further teaching or clarification, because it is incorrect and exaggerated. Spreading HIV through contact with surfaces is not possible or likely, as the virus does not survive long outside the body, and is not transmitted by casual contact, such as touching, hugging, or sharing utensils. Wearing gloves in public is not necessary or advisable, as it can create a false sense of security, stigma, or discrimination. People with HIV should practice good hygiene, such as washing hands, covering coughs, and cleaning wounds, but they do not need to wear gloves or other protective equipment in public.