The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client with heart failure. Which assessment finding supports the use of this diagnosis for the client?
A) Shortness of breath with ambulation
B) Productive cough
C) + 3 pitting edema both feet
D) Heart rate 104 and regular
Answer: C
Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Impaired Perfusion would be a diagnosis applicable for a heart rate of 104 and regular.
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