A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem?
The client has a weight gain of 2 lb (1 kg) per month.
The client eats 90% of meals and snacks.
The client chooses high-protein food.
The client has decreased oral discomfort.
The Correct Answer is A
Choice A rationale:
Weight gain is the most objective and reliable indicator of improved nutritional status in clients with wasting syndrome. It directly reflects an increase in lean body mass, which is essential for restoring health and function.
A weight gain of 2 lb (1 kg) per month is considered a safe and achievable goal for clients with HIV-III and wasting syndrome. This rate of weight gain promotes gradual replenishment of nutrient stores without overwhelming the body's systems.
While other assessment findings, such as increased food intake or decreased oral discomfort, may be positive signs, they do not necessarily guarantee that nutritional goals have been met. It's possible for a client to consume more calories without experiencing weight gain due to factors such as malabsorption or increased metabolic demands. Similarly, decreased oral discomfort may improve appetite but not ensure adequate nutrient intake.
Choice B rationale:
While eating 90% of meals and snacks is a positive sign, it does not guarantee adequate nutrient intake or weight gain. The client may still be consuming insufficient calories or experiencing malabsorption.
The focus of nutritional intervention for wasting syndrome is to increase lean body mass, which is best reflected by weight gain. Eating patterns alone may not accurately capture this progress.
Choice C rationale:
Choosing high-protein foods is important for supporting tissue repair and immune function, but it does not guarantee adequate overall caloric intake or weight gain. The client may still be consuming insufficient calories or experiencing malabsorption.
Weight gain is a more comprehensive indicator of improved nutritional status, as it reflects both protein intake and overall caloric balance.
Choice D rationale:
Decreased oral discomfort can improve appetite and facilitate food intake, but it does not guarantee adequate nutrient intake or weight gain. The client may still be consuming insufficient calories or experiencing malabsorption.
Weight gain is a more direct and reliable indicator of improved nutritional status, as it reflects the actual utilization of nutrients for tissue repair and growth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Offer the client options in the health care provided to him or her: This intervention recognizes the client's autonomy and empowers them to make choices about their healthcare. By offering options, the nurse respects the client's preferences and allows them to participate in decision-making, which can enhance their sense of control and satisfaction with their care.
B. Defer to the client in all matters of health care: While it's important to respect the client's autonomy and involve them in decision-making, deferring to the client in all matters of healthcare may not always be appropriate. Healthcare decisions should be made collaboratively, considering the client's preferences along with the healthcare provider's expertise and evidence-based practice.
C. Ask open-ended questions to determine health knowledge: Open-ended questions encourage the client to express their thoughts, concerns, and preferences freely. By asking open-ended questions, the nurse can gain insight into the client's level of health literacy, understanding of their condition, and preferences for care. This information can inform the development of a tailored care plan that meets the client's individual needs.
D. Encourage the client to join the resident council: Joining the resident council allows the client to actively participate in decision-making processes within the long-term care facility. It provides them with a platform to voice their opinions, advocate for their needs, and contribute to the improvement of facility policies and practices. This involvement can enhance the client's sense of empowerment, social connectedness, and overall satisfaction with their living environment.
E. Inform the client that the healthcare provider has the final say in care: While healthcare providers play a crucial role in guiding and implementing healthcare decisions, it's essential to emphasize shared decision-making and collaborative care. Informing the client that the healthcare provider has the final say may undermine their autonomy and discourage active participation in decision-making. Instead, the focus should be on fostering a partnership between the client and healthcare team, where decisions are made collaboratively based on mutual respect, trust, and shared goals.
Correct Answer is A
Explanation
A. Fried chicken with collard greens: Fried foods are high in fat, which can exacerbate symptoms of pancreatitis. Collard greens, although a vegetable, are often prepared with added fats. This choice would warrant a teaching plan on avoiding high-fat foods to prevent aggravating pancreatitis.
B. Grilled salmon with summer squash: Grilled salmon is a lean protein source and summer squash is a low-fat vegetable. This choice aligns well with dietary recommendations for pancreatitis management, so no additional teaching plan may be necessary.
C. Tomato sandwich on white bread: Tomatoes are acidic and may cause discomfort for some individuals with pancreatitis. White bread is refined and lacks fiber, which may not be ideal for digestive health. This choice could prompt a teaching plan on selecting foods that are gentle on the digestive system and higher in fiber.
D. 2% milk with high-fiber cereal: While 2% milk is not excessively high in fat, it still contains some fat which may be problematic for pancreatitis. High-fiber cereal is generally a good choice, but it depends on the specific ingredients and whether they are well-tolerated by the individual. This choice could lead to a teaching plan on selecting low-fat dairy alternatives and choosing high-fiber foods that are easier on the digestive system.
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