The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurse's plan of care should prioritize what nursing diagnosis?
A) Risk for infection related to lymphedema
B) Disturbed body image related to lymphedema
C) Ineffective health maintenance related to lymphedema
D) Risk for deficient fluid volume related to lymphedema
Ans: A
Feedback:
Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The patient's body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat to the patient's physiological well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid volume is not a significant risk.
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