A 17-year-old girl has been diagnosed with bulimia nervosa.

Which complication should the nurse carefully assess for in this client?

Choice A rationale

Pain assessment and management are important components of comprehensive care for any child, including those with HIV, especially following invasive procedures. However, the immediate physiological priority in managing a child with a chronic, immunosuppressive disease like HIV is maintaining immune function and suppressing viral replication through scheduled medication administration to prevent opportunistic infections.

Choice B rationale

Reviewing the absolute CD4+ T-lymphocyte count daily provides information about the degree of immunosuppression, as a normal count for a child varies by age but indicates immune health. While monitoring this parameter is vital for guiding treatment and prophylaxis, the active administration of antiretroviral medications and prophylactic antibiotics is the priority intervention to directly protect the child's immune system.

Choice C rationale

Administering prescribed antiretroviral medications (ART) and prophylactic antibiotics is the priority nursing intervention for a child with Human Immunodeficiency Virus (HIV) infection. Adherence to the ART regimen is critical for maintaining viral suppression, preventing disease progression to AIDS, and preserving the function of the child's severely compromised immune system, thereby reducing the risk of life-threatening opportunistic infections.

Choice D rationale

Assisting the child with daily activities, such as bathing, feeding, and mobility, is part of supportive care. This promotes comfort and physical well-being, especially during periods of illness or fatigue. However, this is a supportive measure, whereas administering medications directly addresses the underlying pathological process of immune deficiency, making medication administration the higher-priority intervention.

Step 1 is to calculate the total IV intake. The IV ran for 4 hours (from 0100 to 0500). 60 mL/hour × 4 hours = 240 mL.

Step 2 is to convert the apple juice container volume from ounces to milliliters. 1 ounce is approximately 30 milliliters. 3 ounces per container × 30 mL/ounce = 90 mL per container.

Step 3 is to calculate the total apple juice intake. 2 containers × 90 mL/container = 180 mL.

Step 4 is to calculate the total water intake (already in mL). Water intake = 360 mL.

Step 5 is to calculate the total oral intake. 180 mL (apple juice) + 360 mL (water) = 540 mL.

Step 6 is to calculate the total intake (IV and oral) in milliliters. 240 mL (IV) + 540 mL (oral) = 780 mL. The patient's total intake (IV and oral) from 0100 to 0500 was 780.