A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?

A. Mutually establish desired outcomes of the plan of care:

While establishing desired outcomes is an important part of the nursing process, nursing diagnoses themselves do not necessarily focus on mutually establishing these outcomes. Nursing diagnoses help identify health problems and needs, which then guide the development of outcomes during the planning phase.

B. Guide selection of nursing interventions to meet expected outcomes:

This is the correct answer. Nursing diagnoses help determine the specific needs and problems a patient is facing. Once identified, nursing interventions can be chosen to address these needs and work towards achieving expected outcomes.

C. Establish a database of information for future comparison:

Establishing a database of information is more related to the assessment phase of the nursing process. Nursing diagnoses are formulated based on the analysis of the collected data and serve to guide subsequent steps in the nursing process, particularly planning and intervention.

D. Evaluate the effectiveness of the established plan of care:

Evaluating the effectiveness of the established plan of care is part of the later stages of the nursing process. Nursing diagnoses help in planning and implementing interventions, and evaluating their effectiveness comes after these interventions have been carried out.

A. Client reports feeling dizzy when sitting up from a supine position.

Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.

B. Client reports feeling palpitations when rising from a supine to a standing position.

Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.

C. Erythema is present on the bilateral lower extremities.

Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.

D. The client has a temperature of 100.4 F.

Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.

E. The client states, “I feel lightheaded when sitting up.”

Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.