An elderly patient has received a neuromuscular junction blocker during surgery. What would be an appropriate nursing diagnosis for this patient?
A) Excess fluid volume
B) Risk for impaired skin integrity
C) Deficient fluid volume
D) Chronic confusion
B
Feedback:
An elderly or frail patient will need extra nursing care to prevent skin breakdown during the period of paralysis because skin tends to be thinner and more susceptible to breakdown. Therefore, risk of impaired skin integrity would be an appropriate nursing diagnosis. Fluid excess or deficit should not be a concern and the patient may be acutely confused when awakening, but there is no reason to think he or she would remain chronically confused if he was not before surgery.
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