Which of the following patient problems is given the highest priority by the nurse?
a. Anxiety related to hospitalization as manifested by hyperactive state
b. Impaired tissue perfusion, cerebral, related to hypoxia as manifested by decreased level of consciousness
c. Impaired skin integrity related to surgical incision
d. Risk for fluid volume overload related to imbalance in antidiuretic hormone as manifested by peripheral edema and decreased sodium
ANS: B
A
Anxiety is a psychological, not a physical or life-threatening, problem.
B
Impaired tissue perfusion, cerebral, is life threatening and would take priority.
C
Impaired skin integrity has a potential for harm but does not take priority over cerebral tissue perfusion problems.
D
Risk for fluid volume overload related to imbalance in antidiuretic hormone as manifested by peripheral edema and decreased sodium is a potential problem and does not take priority over actual problems.
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