A nurse is caring for a client who was recently admitted for treatment of cirrhosis. The client is currently experiencing BP of 200/100 mmHg, +3 pitting edema, and shortness of breath
Which nursing diagnosis should the nurse select as a priority for this client?
A) Excess Fluid Volume
B) Ineffective Tissue Perfusion
C) Deficient Fluid Volume
D) Impaired Skin Integrity
Answer: A
The client experiencing shortness of breath, edema, and hypertension should have a care plan for fluid volume excess. Hypertension, shortness of breath, and edema are manifestations of fluid excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective Tissue Perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.
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