A nurse assesses a client with cirrhosis who is experiencing hypertension, edema, and shortness of breath. For which diagnosis should the nurse develop a plan of care?
1. Deficient Fluid Volume
2. Ineffective Tissue Perfusion
3. Excess Fluid Volume
4. Impaired Skin Integrity
3. Excess Fluid Volume
Rationale:
The client experiencing shortness of breath, edema, and hypertension should have a care plan for fluid volume excess. Hypertension, shortness of breath, and edema are manifestations of fluid 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.
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The nurse is caring for a patient who is receiving intravenous theophylline. The patient complains of headache and nausea. The nurse will contact the provider to
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The nurse is counseling a young couple who in 2 months are having their third baby. The nurse uses Von Bertalanffy's general system theory applied to families to analyze the family structure
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