A client who has type 2 diabetes is scheduled for the removal of a skin lesion on his right shoul-der at an ambulatory surgery unit. The nursing diagnosis the client is at greatest risk for postoper-atively is:
1. Risk for injury
2. Risk for infection
3. Impaired wound healing
4. Imbalanced nutrition: less than body requirements
ANSWER
ANS: 3
Diabetes increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment. The stress of surgery often causes increases in blood glucose levels. Although all the options present with possible nursing diagnoses, the re-maining options are not of primary concern because steps can be taken (e.g., antibiotic, intrave-nous fluids) to minimize the risk. Impaired wound healing is not as easily managed.
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