While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
Alteration in body image
Alteration in activity tolerance
Impaired tissue perfusion
Impaired skin integrity
The Correct Answer is C
Impaired tissue perfusion is a nursing diagnosis that indicates a decrease in oxygen and nutrient delivery to the tissues, resulting in cellular dysfunction and potential tissue damage or necrosis. It is the priority nursing diagnosis for a client who has varicose veins with ulcerations and lower extremity edema, as these are signs of chronic venous insufficiency, which is a condition in which the veins in the legs fail to return blood to the heart effectively, causing blood to pool and stagnate in the lower extremities. This leads to increased venous pressure, inflammation, and impaired wound healing, which can cause skin breakdown, infection, and tissue necrosis. The nurse should monitor the client's vital signs, peripheral pulses, capillary refill, skin color, temperature, and sensation, and implement interventions to improve venous return and prevent further complications, such as elevating the legs, applying compression stockings, encouraging ambulation, administering medications, and providing wound care.
Alteration in body image. This is a nursing diagnosis that indicates a negative perception or dissatisfaction with one's physical appearance or function. It may be applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these may affect their self-esteem and social interactions. However, it is not the priority nursing diagnosis for this client, as it does not pose an immediate threat to their health or safety.
Alteration in activity tolerance. This is a nursing diagnosis that indicates a decrease in the ability to perform physical activities without experiencing fatigue, dyspnea, or other symptoms. It may be applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these may limit their mobility and endurance. However, it is not the priority nursing diagnosis for this client, as it does not pose an immediate threat to their health or safety.
Impaired skin integrity. This is a nursing diagnosis that indicates a disruption or damage to the epidermis or dermis layers of the skin. It is applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these can cause skin breakdown and infection. However, it is not the priority nursing diagnosis for this client, as it is a consequence of impaired tissue perfusion, which is the underlying problem that needs to be addressed first.
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Related Questions
Correct Answer is C
Explanation
Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
Correct Answer is D
Explanation
Hemorrhagic stroke is a type of stroke that occurs when a blood vessel ruptures in the brain, causing bleeding and increased intracranial pressure. The client's symptoms of sudden, severe headache, vomiting, seizure, and
unresponsiveness are consistent with hemorrhagic stroke. The client's elevated blood pressure and temperature are also risk factors for hemorrhagic stroke.
Thrombotic stroke is a type of stroke that occurs when a blood clot forms in an artery that supplies blood to the brain, causing ischemia and tissue damage. The client's symptoms are not typical of thrombotic stroke, which usually has a gradual onset and affects one side of the body.
Transient ischemic atack (TIA) is a temporary interruption of blood flow to the brain, causing neurologic deficits that resolve within 24 hours. The client's symptoms are not indicative of TIA, which does not cause loss of consciousness or permanent brain damage.
Embolic stroke is a type of stroke that occurs when a blood clot or other debris travels from another part of the body to the brain, causing occlusion and ischemia. The client's symptoms are not characteristic of embolic stroke, which usually has a sudden onset and affects one side of the body.
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