Upon assessment of the patient, the nurse notes the following data: decrease in urine output, decrease in blood pressure, weak pulse that increases when the patient stands, and a urine specific gravity of 1.030
The priority nursing diagnosis formulated by the nurse based upon this data is:
A) Deficient fluid volume
B) Hyperthermia
C) Unbalanced nutrition, less than body requirements
D) Ineffective protection
Ans: A
Feedback: Fluid and electrolyte imbalances are common in the patient with HIV. Dehydration may be indicated by increased thirst; decreased urine output; low blood pressure, or a decrease in systolic blood pressure between 10 and 15 mm Hg with a concurrent rise in pulse rate when the patient sits up or stands; weak and rapid pulse; and urine specific gravity of 1.025 or more. Since this patient exhibits signs of dehydration, the priority nursing diagnosis is deficient fluid volume. Hyperthermia may also contribute to a fluid volume deficit, but based on the information presented it cannot be assumed. Unbalanced nutritional intake may lead to decreased fluid intake, but based upon the information presented it cannot be assumed. Ineffective protection is also a likely nursing diagnosis for this patient but does not pertain to the data presented.
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