Exhibits

The nurse reviews the client's data.

Choose the most likely options for the information missing from the sentence by selecting from the lists of options provided.

The client's assessment findings of

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and

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places him at a high risk for multiple other health issues and requires immediate follow up by the nurse.

A. Enzyme immunoassay. The enzyme immunoassay (EIA), also known as the ELISA test, is used as a primary screening test for HIV. If the EIA test is positive, a confirmatory test, such as the Western Blot, is performed to ensure accuracy.

B. Western Blot. The Western Blot is a confirmatory test for HIV used to verify positive results from an initial screening test. It detects specific HIV antibodies and is highly specific, reducing the likelihood of false positives.

C. White blood cell differential. A white blood cell (WBC) differential assesses the overall immune response but does not diagnose HIV. While some HIV patients may show low WBC counts, this test is not specific for HIV infection.

D. CD4+ cell count. CD4+ cell count is used to monitor disease progression and immune function in HIV-positive patients, but it is not a confirmatory test for diagnosing HIV. A low CD4+ count suggests HIV progression toward AIDS rather than initial diagnosis.

The client's assessment findings of neuropathy and incontinence place him at a high risk for multiple other health issues and require immediate follow-up by the nurse.

Rationale:

Neuropathy. The client reports neuropathy in both hands and lower legs. Neuropathy leads to decreased sensation, increasing the risk of falls, pressure injuries, and unnoticed wounds, which can become severe due to diabetes-related poor healing. It also contributes to mobility limitations, further affecting the client’s safety and independence.

Incontinence. The client experiences urinary and fecal incontinence due to difficulty moving quickly enough to reach the bathroom. Incontinence increases the risk of skin breakdown, infections, and pressure ulcers, especially since the client has mobility issues and spends prolonged time sitting.

Moist skin. While moist skin may suggest sweating or autonomic dysfunction, it is not as significant a risk factor as neuropathy and incontinence, which directly impact skin integrity and mobility.

Coarse lung sounds. Coarse lung sounds may indicate fluid retention or respiratory congestion, but they are not as immediately concerning as neuropathy and incontinence, which increase the risk for skin damage, infection, and functional decline.