What Nursing Diagnosis would be a priority for a client who has had a large surgical wound from recent colon surgery, the client is obese, and the client is taking corticosteroid medications?
Anxiety.
Self-care Deficit.
Risk for Infection.
Risk for Imbalanced Nutrition.
The Correct Answer is C
Choice A rationale:
Anxiety is a valid concern for any client undergoing surgery, but it is not the priority nursing diagnosis in this case. The client's risk for infection is more pressing due to the following factors:
Large surgical wound: Wounds provide a potential entry point for pathogens.
Obesity: Excess adipose tissue can impair wound healing and increase the risk of infection.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Choice B rationale:
Self-care Deficit may be a concern if the client has difficulty caring for the surgical wound or maintaining hygiene due to obesity. However, it is not the priority diagnosis in this case. The focus should be on preventing infection, which would also help to address any self-care deficits.
Choice D rationale:
Risk for Imbalanced Nutrition is a relevant diagnosis for a client who has had colon surgery, as they may experience changes in appetite, digestion, or absorption of nutrients. However, it is not the priority diagnosis in this scenario. Preventing infection is crucial to ensure proper wound healing and overall recovery.
Choice C rationale:
Risk for Infection is the priority nursing diagnosis for this client due to the following risk factors: Large surgical wound: The wound provides a potential entry point for bacteria and other pathogens.
Obesity: Excess adipose tissue can impair wound healing by reducing blood flow to the area and increasing the risk of wound dehiscence (separation of wound edges). This can create a favorable environment for bacterial growth.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Nursing interventions to address Risk for Infection:
Assess the wound regularly for signs of infection, such as redness, swelling, warmth, pain, or purulent drainage. Implement strict aseptic technique when caring for the wound.
Teach the client about proper wound care and hygiene practices.
Monitor the client for signs of systemic infection, such as fever, chills, or malaise. Administer antibiotics as prescribed.
Encourage adequate nutrition and hydration to support wound healing.
Collaborate with the healthcare team to manage the client's risk factors for infection.
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Related Questions
Correct Answer is C
Explanation
Choice A Rationale:
Hemorrhage is not a direct risk associated with antibiotic use and diarrhea. While severe diarrhea can lead to fluid loss and potentially hypovolemia, it's not the most significant risk in this context.
Antibiotics themselves don't typically cause bleeding issues unless they specifically interfere with clotting factors, which isn't common.
The nurse should monitor for signs of bleeding, but it's not the primary concern based on the patient's history of antibiotic use and diarrhea.
Choice B Rationale:
Cardiovascular collapse is a serious complication, but it's not directly linked to antibiotic use and diarrhea. It can occur due to various factors like severe dehydration, electrolyte imbalances, or underlying heart conditions. The nurse should be vigilant for signs of cardiovascular instability, but it's not the most likely risk in this scenario.
Choice C Rationale:
Electrolyte imbalances are a significant concern for patients with diarrhea, especially those on antibiotics. Antibiotics can disrupt the balance of gut bacteria, which play a crucial role in electrolyte absorption. Diarrhea further exacerbates electrolyte loss through fluid loss.
Key electrolytes to monitor include:
Potassium: Essential for nerve and muscle function, including the heart. Low potassium (hypokalemia) can lead to muscle weakness, fatigue, cramps, and potentially heart arrhythmias.
Sodium: Vital for fluid balance and nerve signaling. Low sodium (hyponatremia) can cause confusion, seizures, and coma.
Chloride: Also important for fluid balance and acid-base balance.
Magnesium: Crucial for muscle function, nerve transmission, and energy production. Low magnesium (hypomagnesemia) can cause muscle cramps, tremors, and heart arrhythmias.
The nurse should closely monitor the patient's electrolyte levels and watch for signs of imbalance, such as muscle weakness, fatigue, cramps, confusion, or heart rhythm abnormalities.
Choice D Rationale:
Respiratory paralysis is not a typical risk associated with antibiotic use or diarrhea.
It's more commonly linked to neuromuscular disorders, certain medications, or severe electrolyte imbalances (especially low potassium or calcium).
While the nurse should be aware of potential respiratory complications, it's not the most likely concern in this case.
Correct Answer is C
Explanation
Choice A rationale:
While independence is a valuable quality for nurses, it's not the most essential quality for leadership. Effective leaders must be able to collaborate with others, delegate tasks, and build consensus. They must also be able to recognize when they need to seek help or guidance from others.
Choice B rationale:
Physical stamina is important for nurses, as they often work long hours and are on their feet for extended periods. However, it's not the most essential quality for leadership. Leaders need to be able to think clearly, make decisions under pressure, and motivate others, even when they are tired or stressed.
Choice C rationale:
Flexibility is essential for nursing leaders because the healthcare environment is constantly changing. Leaders must be able to adapt to new situations, challenges, and demands. They must also be able to adjust their leadership style to meet the needs of different individuals and teams.
Here are some examples of how flexibility is essential for nursing leaders:
Managing change: Leaders must be able to effectively manage change, such as new policies, procedures, or technologies. They need to be able to communicate changes clearly, provide support to staff, and ensure that changes are implemented smoothly.
Dealing with conflict: Leaders must be able to resolve conflicts effectively, whether between staff members, patients, or families. They need to be able to listen to different perspectives, identify common ground, and find solutions that meet the needs of all parties involved.
Adapting to different personalities: Leaders must be able to work with a variety of personalities and work styles. They need to be able to adjust their communication style, provide feedback, and motivate individuals in a way that is tailored to their needs.
Responding to crises: Leaders must be able to act quickly and decisively in crisis situations. They need to be able to assess the situation, make decisions, and take action to protect the safety of patients and staff.
Choice D rationale:
Vulnerability can be a valuable quality for leaders, as it can help to build trust and rapport with others. However, it's not the most essential quality for leadership. Leaders need to be able to balance vulnerability with strength and confidence.
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