Nokea
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as the priority in the client's care?
Correct Answer: C
Rationale: Varicose veins with ulcerations, edema, and heaviness scream venous stasis impaired skin integrity tops the list as open sores risk infection, a pressing threat needing immediate wound care. Ineffective perfusion drives the issue, but skin breakdown's acuity trumps. Body image matters emotionally, less urgently. Activity tolerance lags behind active complications. Nurses prioritize skin integrity, addressing ulcers' vulnerability, a direct care focus to halt deterioration in this chronic venous picture, aligning with safety and healing goals.