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 A

Explanation

A. Obstructive sleep apnea: Obstructive sleep apnea is characterized by loud snoring, daytime drowsiness, and periods of waking up due to blocked airways. The client’s symptoms are consistent with this condition and warrant further assessment for it.

B. Circadian rhythm disorder: Circadian rhythm disorders involve disruptions in the sleep-wake cycle, but they are less likely to present with loud snoring and daytime drowsiness as primary symptoms.

C. Narcolepsy: Narcolepsy is characterized by excessive daytime sleepiness and sudden sleep attacks but does not typically include loud snoring or waking up from snoring.

D. Insomnia: Insomnia involves difficulty falling or staying asleep and would not typically cause daytime drowsiness from loud snoring or the described waking up issues.

A. You have plenty of time to figure all of that out." B. "Decisions will then be made for your spouse by the health care provider." C. "Decisions should be made now for your spouse's future." D. I can explain advance care planning to you."

Correct Answer is D

Explanation

A. "You have plenty of time to figure all of that out." This response is not proactive and may not address the urgency of planning for future decisions. It is important to address these issues sooner rather than later.

B. "Decisions will then be made for your spouse by the health care provider." Healthcare providers will make decisions based on medical criteria and the patient's current condition, but they will typically follow the wishes expressed in advance directives or legal documents.

C. "Decisions should be made now for your spouse's future." This is a proactive approach, but it's important to involve the spouse in the decision-making process.

D. "I can explain advance care planning to you." This is the most appropriate response. Advance care planning involves discussing the client's wishes regarding their future care, including decisions about life-sustaining treatments. By explaining this process, the nurse can help the spouse prepare for a time when the client may be unable to make their own decisions.

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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 caring for a client who reports daytime drowsiness. The client states, "My partner says my snoring is getting louder and it sometimes wakes me up." The nurse should further assess the client for which of the following?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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