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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
This statement is incorrect because it trivializes the patient's concerns and implies that enjoyment is the primary goal, which is not the case. The main purpose of cardiac rehabilitation is to improve health outcomes, not just to make the routine enjoyable.
Choice B reason:
While exercise is beneficial for heart health, this statement is too general and does not address the specific benefits of cardiac rehabilitation for someone who has had a myocardial infarction.
The correct answer is C:
"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." Cardiac rehabilitation is crucial for patients who have experienced a myocardial infarction. It provides a structured program that includes exercise, education, and support to help patients improve their cardiovascular health and prevent future cardiac events.
Choice D reason:
Deferring to the doctor's expertise does not educate the patient about the benefits of cardiac rehabilitation. It's important for patients to understand why they are participating in the program.
Correct Answer is B
Explanation
Changing the dressing within 12 hours of the procedure is an important instruction for the client following a cardiac catheterization, as it helps prevent infection and monitor bleeding at the incision site.
a. "You will notice a small hematoma at the incision site." is not correct, as a hematoma is an abnormal finding that indicates bleeding or hematoma formation. The client should report any swelling, bruising, or oozing at the incision site to the provider.
c. "You can resume regular exercise as soon as tomorrow." is not appropriate, as the client should avoid strenuous activity and heavy lifting for at least 24 hours after the procedure, or as directed by the provider.
d. "Pain medication will not be necessary." is not accurate, as the client may experience some mild discomfort or soreness at the incision site, which can be relieved by taking over-the-counter analgesics, unless contraindicated.
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