The nurse contributes to the plan of care for a patient with hypertension. Which of the following nursing diagnoses is the focus of care for the patient with hypertension?

A. Place three pillows between the legs, one distal and three proximal: This is incorrect and excessive. Using three pillows in this manner can lead to improper leg positioning and discomfort.
B. Side-lying position is permitted with a pillow between the legs: While side-lying is allowed, the pillow is to prevent adduction of the legs, not just any pillow placement. It must specifically keep the hips aligned.
C. Sitting in a bedside chair is permitted if the legs are elevated: While sitting is often encouraged, elevating the legs too high can risk hip dislocation or improper alignment. The patient should sit in a way that maintains proper hip angles and alignment.
D. A triangular pillow is used between the legs to avoid adduction: A triangular or abduction pillow helps keep the legs in an appropriate position, preventing the legs from crossing and reducing the risk of hip dislocation post-surgery.

Correct answer: A
A. Monitoring for infection: Infection is a significant risk with external fixation devices due to the presence of pins that penetrate the skin and soft tissues. Monitoring for signs of infection, such as redness, swelling, discharge, or increased pain, is crucial.
B. Monitoring circulatory status: While circulatory status is important, especially in cases of limb injury or immobilization, it is not the most immediate concern compared to the risk of infection from the external fixation device.
C. Validating proper mobility: Ensuring proper mobility is important, but it is secondary to the prevention and detection of infection. Mobility assessments can be done after confirming that there are no infections or complications.
D. Checking discomfort level: While assessing discomfort is important for pain management and comfort, it is not as critical as monitoring for infection, which can lead to severe complications if not addressed promptly.