A nurse is caring for a client who was recently admitted for treatment of cirrhosis. The client is currently experiencing ascites, +3 pitting edema, and oliguria. Which nursing diagnosis should the nurse select as a priority for this client?
A)Excess Fluid Volume
B)Ineffective Peripheral Tissue Perfusion
C)Deficient Fluid Volume
D)Impaired Skin Integrity

Question

Quizplus · Accepted Answer

A)The client experiencing ascites, edema, and oliguria should have a care plan for fluid volume excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.
B)The client experiencing ascites, edema, and oliguria should have a care plan for fluid volume excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.
C)The client experiencing ascites, edema, and oliguria should have a care plan for fluid volume excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.
D)The client experiencing ascites, edema, and oliguria should have a care plan for fluid volume excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.

A Nurse Is Caring for a Client Who Was Recently