A 58-year-old patient who has undergone a radical vulvectomy for vulvar carcinoma returns to the medical-surgical unit after the surgery. The priority nursing diagnosis for the patient at this time is
a. risk for infection related to contact of the wound with urine and stool.
b. self-care deficit: bathing/hygiene related to pain and difficulty moving.
c. imbalanced nutrition: less than body requirements related to low-residue diet.
d. risk for ineffective sexual pattern related to disfiguration caused by the surgery.
ANS: A
Complex and meticulous wound care is needed to prevent infection and delayed wound healing. The other nursing diagnoses may also be appropriate for the patient but are not the highest priority immediately after surgery.
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