The nurse is developing the plan of care for a patient who is unable to bear weight on the right foot. The patient requires assistance to get out of bed and has recently fallen. Which of the following nursing diagnosis would be most appropriate for this patient?

Acute pain

Risk for injury

Activity Intolerance

Toileting self-care deficit

Answer and Explanation

The Correct Answer is B

A. Acute pain: This diagnosis might be relevant if the patient has pain, but it does not address the main concern of mobility and risk related to recent falls.

B. Risk for injury: This is the most appropriate diagnosis as the patient’s inability to bear weight and recent falls increase their risk of further injury.

C. Activity Intolerance: While the patient may have activity intolerance, the more pressing concern related to their recent falls and inability to bear weight is the risk for injury.

D. Toileting self-care deficit: This diagnosis might be relevant if there were specific issues with toileting, but it is not the most appropriate for the general risk of injury due to recent falls.

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Correct Answer is D

Explanation

A. "Are you usually anxious about unknown situations?" This question may help understand the client's general anxiety but does not directly address the specific concern related to their current hospital admission.

B. "Do you have any questions about this admission?" This response is practical and offers the client an opportunity to clarify any doubts about the current admission, which might help reduce anxiety.

C. "Are you here for the same reason?" This question is specific to the reason for the admission but may not fully address the anxiety related to the hospital environment.

D. "Can you tell me more about that experience?" This response encourages the client to discuss their previous negative experience, which can help in understanding their anxiety and providing targeted support.

A. Apply the stockings once the patient has gotten out of bed for the day. B. Massage the patient's legs before application of the stockings. C. Measure both patient's legs to determine the proper stocking size. D. Assess the patient's pedal pulses before application of stockings.

Correct Answer is C

Explanation

A. Apply the stockings once the patient has gotten out of bed for the day. Compression stockings should be applied while the patient is still in bed, before they get up, to avoid issues with blood flow and to ensure proper fit.

B. Massage the patient's legs before application of the stockings. Massaging the legs before applying compression stockings can help in reducing swelling and ensuring proper application.

C. Measure both patient's legs to determine the proper stocking size. Measuring the legs is crucial to ensure that the stockings fit properly and provide the correct level of compression.

D. Assess the patient's pedal pulses before application of stockings. Checking pedal pulses is important to ensure adequate blood flow and to avoid complications with the use of compression stockings.

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The nurse is developing the plan of care for a patient who is unable to bear weight on the right foot. The patient requires assistance to get out of bed and has recently fallen. Which of the following nursing diagnosis would be most appropriate for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client to the hospital. The client states, "Hospitals make me anxious ever since my last visit. Which of the following would be the most appropriate response by the nurse?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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