The nurse is planning care for a client in shock and determines the priority nursing diagnosis is:
a. Excess fluid volume related to overload of intravenous fluids.
b. Impaired skin integrity related to invasive monitoring devices.
c. Activity intolerance related to increased cardiac workload.
d. Ineffective tissue perfusion related to trauma.
ANS: D
Feedback
A Incorrect: Although a possible nursing diagnosis, the question does not provide sufficient information for it.
B Incorrect: Although a possible nursing diagnosis, it is not the priority one.
C Incorrect: Although a possible nursing diagnosis, it is not the priority one.
D Correct: This is the priority nursing diagnosis for a client in shock, because regardless of the type of shock, hypoperfusion occurs.
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