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 D
Explanation
The nurse should place a towel under the client's head to protect it from injury during the seizure. The nurse should also loosen any tight clothing, remove any objects that could harm the client, and maintain a patent airway.
Place the client in a prone position is wrong because it can compromise the client's breathing and increase the risk of aspiration. The nurse should place the client in a side-lying position after the seizure to facilitate drainage of oral secretions and prevent aspiration.
Holding the client's arms and legs still is wrong because it can cause injury to the client or the nurse. The nurse should not restrain or interfere with the client's movements during the seizure but rather ensure a safe environment and observe the seizure activity.
Leaving the client to get help is wrong because it can endanger the client's safety and well-being. The nurse should stay with the client during the seizure and call for assistance if needed, but not leave the client alone or unattended.
Correct Answer is A
Explanation
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
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