A client diagnosed with HIV infection is receiving HAART. The client, who is alert and oriented, complains of anorexia, nausea, and vomiting. He has lost 10 pounds in the last 6 weeks
Additional assessment reveals pale, pink skin without any irritation or breakdown. He denies any complaints of pain. Which nursing diagnosis would the nurse identify as the priority for this client?
A) Risk for Injury
B) Risk for Imbalanced Nutrition: Less Than Body Requirements
C) Risk for Impaired Skin Integrity
D) Acute Pain
Ans: B
Feedback:
The client's complaints along with his weight loss strongly suggest a nursing diagnosis of Risk for Imbalanced Nutrition: Less Than Body Requirements as a priority. The client is alert and oriented, so his risk for injury is significantly low. There is no evidence of impaired skin integrity at present. However, this may become a concern if the client begins to experience skin breakdown secondary to his poor nutritional status. The client denies any pain, so Acute Pain would be inappropriate.
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