A client with acute renal failure has jugular vein distention,lower extremity edema,and elevated blood pressure.Based on this data,which nursing diagnosis is the most appropriate?
A) Ineffective Renal Tissue Perfusion
B) Excess Fluid Volume
C) Risk for Altered Cardiac Perfusion
D) Risk for Infection

Question

Quizplus · Accepted Answer

A) Jugular vein distention, edema, and elevated blood pressure are indications of excessive fluid. The diagnosis Excess Fluid Volume should be selected to guide this client's care. Oliguria or reduced urine output would be a symptom associated with Ineffective Renal Tissue Perfusion. Alterations in heart rate and rhythm would be symptoms associated with Risk for Altered Cardiac Perfusion. The client is not demonstrating any manifestations that indicate a Risk for Infection.
B) Jugular vein distention, edema, and elevated blood pressure are indications of excessive fluid. The diagnosis Excess Fluid Volume should be selected to guide this client's care. Oliguria or reduced urine output would be a symptom associated with Ineffective Renal Tissue Perfusion. Alterations in heart rate and rhythm would be symptoms associated with Risk for Altered Cardiac Perfusion. The client is not demonstrating any manifestations that indicate a Risk for Infection.
C) Jugular vein distention, edema, and elevated blood pressure are indications of excessive fluid. The diagnosis Excess Fluid Volume should be selected to guide this client's care. Oliguria or reduced urine output would be a symptom associated with Ineffective Renal Tissue Perfusion. Alterations in heart rate and rhythm would be symptoms associated with Risk for Altered Cardiac Perfusion. The client is not demonstrating any manifestations that indicate a Risk for Infection.
D) Jugular vein distention, edema, and elevated blood pressure are indications of excessive fluid. The diagnosis Excess Fluid Volume should be selected to guide this client's care. Oliguria or reduced urine output would be a symptom associated with Ineffective Renal Tissue Perfusion. Alterations in heart rate and rhythm would be symptoms associated with Risk for Altered Cardiac Perfusion. The client is not demonstrating any manifestations that indicate a Risk for Infection.

A Client with Acute Renal Failure Has Jugular Vein Distention,lower