A client exhibits confusion, decreased capillary refill time, low oxyg

A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal output. What NANDA nursing diagnosis problem statement should the nurse choose for this client?

1. Ineffective Tissue Perfusion
2. Decreased Cardiac Output
3. Activity Intolerance
4. Risk for Injury

ANSWER

Correct Answer: 1
Rationale 1: Ineffective Tissue Perfusion is the diagnosis assigned when there is a decrease in oxygenation from failure to nourish tissues at the capillary level.
Rationale 2: Decreased Cardiac Output is the diagnosis assigned when there is inadequate blood pumped by the heart to meet the demands of the body.
Rationale 3: Activity Intolerance is the diagnosis assigned when the client does not have the energy for daily activities.
Rationale 4: Risk for Injury is the diagnosis assigned when the client has an increased chance of being injured.