The nurse caring for a patient with leg ulcers has finished assessing the patient and is developing a problem list prior to writing a plan of care
What major nursing diagnosis, based on the assessment findings, might the problem list include?
A) Imbalanced nutrition: more than body requirements
B) Inactivity related to age and disease process
C) ROM related to age and disease process
D) Imbalanced nutrition: less than body requirements
Ans: D
Feedback: Based on the assessment data, major nursing diagnoses for the patient may include Impaired skin integrity related to vascular insufficiency; Impaired physical mobility related to activity restrictions of the therapeutic regimen and pain; and Imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing. The scenario does not mention the patient's age, so a nursing diagnosis cannot be formulated based on age. ROM is not a nursing diagnosis.
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