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Dorsal recumbent position: Dorsal recumbent (supine with knees bent) lies the patient flat on their back. This position reduces diaphragmatic excursion and is not optimal for someone who is short of breath.

Lateral position: Side-lying (lateral) may be useful for airway protection, certain respiratory conditions, or to improve ventilation of a dependent lung in unilateral disease, but it is not the standard first choice for general dyspnea.

Sims’ position: Sims’ (semi-prone, used commonly for rectal procedures or enema administration) is not used to relieve dyspnea and may compromise respiratory mechanics.

Risk for Imbalanced Body Temperature related to stage 2 pressure ulcer: A risk diagnosis describes a potential future problem. Although severe infections or large wounds can affect temperature regulation, a stage 2 sacral pressure ulcer in a single area is unlikely to cause an immediate body-temperature imbalance.

Feeding Self-Care Deficit related to blindness: Blindness may impair independent feeding, but it is not inherently as immediately threatening as an existing pressure ulcer that risks infection and further tissue loss. This is an important problem to assess and plan for assistive strategies, but not the highest priority given the current wounds.

Activity Intolerance related to prolonged bed rest: Activity intolerance is likely present and contributes to immobility, but it is more of a contributing/related condition. The immediate problem requiring nursing action on admission is the impaired skin integrity.

Risk for Activity Intolerance: “Risk for…” is used when no current evidence exists but risk factors are present. In this scenario there is current, measurable evidence (vital signs not back to baseline), so an actual diagnosis is appropriate rather than a risk diagnosis.

Impaired Physical Mobility: This focuses on limitation in independent physical movement (ambulation, range of motion). While the client may have limited tolerance, the key problem reported here is the inability to physiologically tolerate activity, not necessarily a limitation of movement itself.

Risk for Disuse Syndrome: This is a risk diagnosis referring to consequences of inactivity (muscle atrophy, bone demineralization, etc.). The client’s immediate problem is demonstrated intolerance to activity, not the future risk of disuse complications.

Gaze is slightly downward: A normal, safe gait is associated with the head up and gaze forward (looking ahead to navigate). A persistently downward gaze can impair balance and increase fall risk.

Toes strike the ground before the heel: Normal walking has a heel-strike (heel contacts first) followed by foot flat and toe-off. Toe-first contact is abnormal and suggests gait deviation.

Arm on the same side as the swing-through foot moves forward at the same time: Normal gait shows reciprocal arm swing: the arm opposite the swing leg moves forward (e.g., right leg forward - left arm forward). Same-side forward movement is abnormal and indicates poor coordination.

Heart rate 86 beats/min: A heart rate of 86 bpm is within normal adult range and does not alone indicate an urgent problem in an immobilized client.

Nonproductive cough: A nonproductive cough may be an early sign of atelectasis or developing pulmonary issue in an immobilized client and should be monitored and managed (incentive spirometry, deep-breathing exercises), but a reddened sacrum is more urgent for preventing tissue breakdown.

Urine output of 50 mL/h: Output of 50 mL/hour is above the commonly used minimum adequate threshold (≥30 mL/hour) and is acceptable. It does not by itself require immediate corrective action.