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The Nurse Is Making a Home Visit to a Client

Question 5

Multiple Choice

The nurse is making a home visit to a client who had a cesarean birth 3 days ago. Assessmentreveals that the client is complaining of intermittent pain, rating it as 8 on a scale of 1 to 10. Shestates, "I'm pretty tired. And with this pain, I haven't been drinking and eating like I should. Themedication helps a bit but not much. My mom has been helping with the baby." Her incision isclean, dry, and intact. Which nursing diagnosis would the nurse identify as the priority for this client?


A) Impaired skin integrity related to cesarean birth incision
B) Fatigue related to effects of surgery and caretaking activities
C) Imbalanced nutrition, less than body requirements related to poor fluid and food intake
D) Acute pain related to incision and cesarean birth

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