A nurse is caring for a client who has a gastrostomy tube and is receiving enteral nutrition. The nurse should identify that which of the following complications represents the greatest risk to the client?

Choice A reason: Reducing caloric intake by 200 calories a day may not be enough to achieve significant weight loss for a client who is obese. The recommended daily calorie deficit for weight loss is 500 to 750 calories, which can result in a loss of 1 to 1.5 pounds per week¹.

Choice B reason: Losing 5 percent of body weight can improve glycemic control and reduce the need for glucose-lowering medications for a client who has type 2 diabetes. Studies have shown that weight loss of 5 to 10 percent can lower HbA1c levels by 0.5 to 1.0 percentage points².

Choice C reason: Exercising for 30 minutes three times a week may not be sufficient to lose 1 pound per week. The recommended amount of physical activity for weight loss is at least 150 minutes of moderate-intensity aerobic exercise per week, plus resistance training at least twice a week³.

Choice D reason: Drinking 16 ounces of apple juice is not advisable if the blood glucose level drops during exercise, as it can cause hyperglycemia. Apple juice contains about 48 grams of carbohydrates, which is equivalent to four servings of glucose tablets⁴. The recommended treatment for hypoglycemia is to consume 15 to 20 grams of fast-acting carbohydrates, such as glucose tablets, gel, or juice, and recheck the blood glucose level after 15 minutes⁵.

Choice A reason: Offering the client a selection of beverages at each meal is not a good action to include in the plan, as it may reduce the client's appetite and intake of solid foods. The nurse should limit the client's fluid intake before and during meals, and encourage the client to consume high-calorie and high-protein drinks, such as milkshakes or smoothies, after meals.

Choice B reason: Informing the client that a weight gain of 2.3 kg (5 lb) per week is expected is not a good action to include in the plan, as it may cause anxiety and resistance in the client. The nurse should set realistic and individualized weight goals for the client, and monitor the client's weight and vital signs regularly. The nurse should also avoid focusing on the client's weight, and instead emphasize the client's health and well-being.

Choice C reason: Arranging for someone to remain with the client for 30 min after meals is a good action to include in the plan, as it can prevent the client from purging or exercising excessively. The nurse should provide a supportive and nonjudgmental environment for the client, and supervise the client's eating and toileting behaviors. The nurse should also educate the client and the family about the complications and treatment of anorexia nervosa.

Choice D reason: Encouraging the client to participate in developing dietary goals is a good action to include in the plan, as it can increase the client's sense of control and motivation. The nurse should collaborate with the client, the dietitian, and the mental health team to create a personalized and flexible meal plan that meets the client's nutritional and psychological needs. The nurse should also praise the client for any progress or achievement, and reinforce the client's positive coping skills.