A client presents with symptoms of alcohol withdrawal and states, "I haven't eaten in three days." A nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97?F (36?C) with dry mucous membranes and poor skin turgor
What should be the priority nursing diagnosis? 1. Knowledge deficit
2. Fluid volume excess
3. Imbalanced nutrition: less than body requirements
4. Ineffective individual coping
3
Rationale: The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.
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Indicate whether this statement is true or false.
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