A patient diagnosed with HIV-II is admitted to the hospital presenting symptoms of fever, night sweats, and a severe cough.

The laboratory results show a CD4+ cell count of 180/mm and a negative tuberculosis (TB) skin test conducted 4 days prior.

What is the first action the nurse should take?

Choice A rationale:
While adequate hydration is important for overall health and urinary function, it does not directly address the priority nursing diagnosis of urinary incontinence. Increased fluid intake without addressing the underlying incontinence can actually exacerbate the problem by increasing urine output.
It's crucial to assess for signs of urinary retention or incomplete bladder emptying, as excessive fluid intake can worsen these conditions.
Individualized fluid intake goals should be established based on the client's overall health status, bladder capacity, and fluid balance.
Choice B rationale:
Satisfaction with incontinence products can improve comfort and quality of life, but it does not necessarily indicate that the underlying issue of incontinence has been resolved.
It's important to evaluate the effectiveness of incontinence products in managing leakage and preventing skin breakdown, but they should not be considered a definitive solution for incontinence.
Explore other interventions to address the root cause of incontinence, such as bladder training, pelvic floor muscle exercises, or medications.
Choice C rationale:
Increased activity and socialization can be positive outcomes of effective incontinence management, but they are not direct measures of the priority nursing diagnosis.
Improved social engagement and activity levels might reflect a reduction in incontinence episodes and increased confidence, but they should not be the sole indicators of success.
Assess for specific changes in incontinence frequency, severity, and impact on daily life to more accurately gauge progress.
Choice D rationale:
Intact, healthy skin in the perineal area is a direct and objective indicator that a priority nursing diagnosis of urinary incontinence has been met.
It demonstrates that the interventions implemented to manage incontinence have been effective in preventing skin breakdown and irritation, which are common complications of incontinence.
This finding aligns with the goal of maintaining skin integrity and preventing infection, which are essential aspects of incontinence care.

Choice A rationale:
Weight gain is the most objective and reliable indicator of improved nutritional status in patients with HIV-II and wasting syndrome. It directly reflects an increase in lean body mass, which is essential for restoring physical strength, immune function, and overall health.
A weight gain of 2 lb (1 kg) in a month is considered a clinically significant improvement for this patient population. It demonstrates that the patient is consuming more calories than they are expending, leading to a positive energy balance and tissue growth.
Other assessment findings, such as food intake, food choices, and oral discomfort, can be subjective and influenced by various factors, such as appetite, taste changes, nausea, fatigue, and psychosocial issues. While they provide valuable information about the patient's nutritional status, they do not directly measure the actual improvement in body composition.
Choice B rationale:
Consuming 90% of meals and snacks is a positive sign that the patient is adhering to their dietary recommendations. However, it does not guarantee that they are consuming enough calories to promote weight gain. The patient's individual energy needs and the nutritional content of the meals and snacks must be considered.
Choice C rationale:
Choosing high-protein foods is important for building and repairing tissues, but it does not ensure adequate overall caloric intake. The patient may still be experiencing a calorie deficit if they are not consuming enough total calories, even if they are focusing on protein-rich foods.
Choice D rationale:
Decreased oral discomfort can facilitate better food intake, but it does not directly reflect weight gain or improved nutritional status. The patient may still have challenges with appetite, nausea, or other factors that hinder their ability to consume enough calories.