What Nursing Diagnosis would be a priority for a client who has had a large surgical wound from recent colon surgery, the client is obese, and the client is taking corticosteroid medications?
Anxiety.
Self-care Deficit.
Risk for Infection.
Risk for Imbalanced Nutrition.
The Correct Answer is C
Choice A rationale:
Anxiety is a valid concern for any client undergoing surgery, but it is not the priority nursing diagnosis in this case. The client's risk for infection is more pressing due to the following factors:
Large surgical wound: Wounds provide a potential entry point for pathogens.
Obesity: Excess adipose tissue can impair wound healing and increase the risk of infection.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Choice B rationale:
Self-care Deficit may be a concern if the client has difficulty caring for the surgical wound or maintaining hygiene due to obesity. However, it is not the priority diagnosis in this case. The focus should be on preventing infection, which would also help to address any self-care deficits.
Choice D rationale:
Risk for Imbalanced Nutrition is a relevant diagnosis for a client who has had colon surgery, as they may experience changes in appetite, digestion, or absorption of nutrients. However, it is not the priority diagnosis in this scenario. Preventing infection is crucial to ensure proper wound healing and overall recovery.
Choice C rationale:
Risk for Infection is the priority nursing diagnosis for this client due to the following risk factors: Large surgical wound: The wound provides a potential entry point for bacteria and other pathogens.
Obesity: Excess adipose tissue can impair wound healing by reducing blood flow to the area and increasing the risk of wound dehiscence (separation of wound edges). This can create a favorable environment for bacterial growth.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Nursing interventions to address Risk for Infection:
Assess the wound regularly for signs of infection, such as redness, swelling, warmth, pain, or purulent drainage. Implement strict aseptic technique when caring for the wound.
Teach the client about proper wound care and hygiene practices.
Monitor the client for signs of systemic infection, such as fever, chills, or malaise. Administer antibiotics as prescribed.
Encourage adequate nutrition and hydration to support wound healing.
Collaborate with the healthcare team to manage the client's risk factors for infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Tertiary health promotion and illness prevention focus on managing existing health conditions and preventing complications. Administering a nebulized bronchodilator to a client who is short of breath directly addresses an existing respiratory problem, aiming to relieve symptoms and prevent further respiratory distress. This intervention falls under tertiary prevention because it targets a client already experiencing respiratory symptoms.
Key points:
Bronchodilators open constricted airways, easing airflow and breathing.
Nebulizers deliver medication directly to the lungs, providing rapid relief.
Shortness of breath is a common symptom of respiratory conditions like asthma and COPD.
Prompt treatment of respiratory symptoms can prevent worsening of the condition and potential complications.
Choice B rationale:
Teaching a client about the risks of light cigarettes is an example of primary prevention. It aims to prevent lung disease before it develops by educating individuals about the harms of smoking.
Choice C rationale:
Advocating for more explicit warning labels on cigarette packages is a form of secondary prevention. It targets at-risk populations (smokers) to encourage behavior change and reduce smoking rates, ultimately lowering the incidence of lung disease.
Choice D rationale:
Assisting with lung function testing is a diagnostic procedure, not a tertiary prevention intervention. It helps to identify respiratory problems but doesn't directly manage or prevent them.
Correct Answer is ["B","C","E"]
Explanation
A. Pale, yellow urine: While pale yellow urine can be a symptom of a UTI, it is not specific enough and can be caused by other factors like dehydration or certain medications. Therefore, it is not a reliable indicator of a UTI in this case.
B. Cloudy urine: Cloudy urine is a more specific symptom of a UTI, as it can indicate the presence of white blood cells or bacteria in the urine. This finding, along with other symptoms, suggests a possible UTI.
C. Suprapubic pain: Suprapubic pain, which is pain felt above the pubic bone in the lower abdomen, is a common symptom of bladder infections, including UTIs. This finding is highly suggestive of a UTI in this client.
D. Temperature of 38.2 C (100.7 F): Although fever can be a symptom of a UTI, it is not always present and can be caused by other infections or conditions. Therefore, a single elevated temperature, without other supporting symptoms, is not conclusive for a UTI diagnosis.
E. Constant urge to urinate (dysuria): Dysuria, or a frequent and urgent need to urinate, is another common symptom of UTIs. This finding, along with cloudy urine and suprapubic pain, further strengthens the suspicion of a UTI in this client.
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