The nurse plans care for the client on a support surface. Which is the nurse's priority nursing diagnosis for the client?

Question

1. Situational anxiety
2. Sensory impairment
3. At risk for constipation
4. At risk for hypovolemia

Answer 1

4
4. The nursing diagnosis dealing with the most serious, and potentially life threaten-ing, complications is At risk for hypovolemia from insensible fluid loss; this is a common disadvantage of support surfaces. The nurse implements suitable nursing care by scrutinizing vital signs, serum protein and electrolyte levels, renal function, mucous membranes, and sudden, excessive weight loss for early detection of client deterioration. In addition, proper nursing care includes administering fluid and elec-trolytes, providing client nutrition including high-quality protein, and promoting skin integrity to prevent fluid escape from ulcers. Adequate protein stores is important for fluid balance because the oncotic pressure provided by plasma proteins is an impor-tant force in maintaining intravascular volume.
1 and 2. A sensory impairment and anxiety are less important for the nurse to manage because, for a client needing a support surface, they have less potential for devastat-ing results.
3. The client at risk for hypovolemia aggravates the risk of constipation because less total body fluid results in fluid removal from the bowel, thus, decreasing the ease of stool passage.