The nurse is assessing a patient admitted with AIDS who is taking a nonnucleoside reverse transcriptase inhibitor. What nursing diagnosis is most likely to be appropriate for this patient?
A) Risk for injury related to central nervous system (CNS) effects of the drug
B) Excess fluid volume related to renal failure
C) Imbalanced nutrition: Less than body requirements, related to gastrointestinal (GI) effects of the drugs
D) Ineffective health maintenance related to spiritual distress
C
Feedback:
The adverse effects most commonly experienced with these drugs are GI related—dry mouth, constipation or diarrhea, nausea, abdominal pain, and dyspepsia. As a result, this patient is most at risk for imbalanced nutrition; less than body requirements. CNS effects are not common with this classification of drug. Renal failure is not a common adverse effect. Nothing indicates the possibility of spiritual distress in this situation.
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