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?

Impaired Physical Mobility

Readiness for Enhanced Health Literacy

Decreased Activity Tolerance

Ineffective Airway Clearance

Answer and Explanation

The Correct Answer is B

A. Impaired Physical Mobility: This is not directly related to hypertension management. While hypertension can affect physical activity, it is not the primary focus in the context of managing high blood pressure.
B. Readiness for Enhanced Health Literacy: This is the correct focus. Educating the patient about hypertension management, lifestyle modifications, and medication adherence is crucial in managing and controlling blood pressure.
C. Decreased Activity Tolerance: This could be a related issue but is not the primary focus. It addresses the impact of hypertension on physical capacity rather than managing the condition itself.
D. Ineffective Airway Clearance: This is unrelated to hypertension. It focuses on respiratory issues rather than blood pressure management.

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Correct Answer is D

Explanation

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.

A. Reducing risk for fall B. Healing the surrounding tissue C. Alignment of the bone D. Immobilization of the leg E. Preventing pain

Correct Answer is ["A","C","D","E"]

Explanation

A. Reducing risk for fall: Patients with fractures are at higher risk for falls, which can exacerbate their injuries or cause new ones. Ensuring the environment is safe and assisting with mobility can reduce this risk.
B. Healing the surrounding tissue: While important, the primary focus in the acute phase is stabilizing the fracture itself. Healing surrounding tissue is more of a long-term goal and indirectly supported by proper fracture management.
C. Alignment of the bone: Proper alignment is crucial for healing. It ensures that the bone ends are in the correct position to heal properly and reduces the risk of complications such as malunion.
D. Immobilization of the leg: Immobilization is necessary to maintain bone alignment and prevent further injury or displacement of the fracture.
E. Preventing pain: Pain management is a fundamental aspect of patient care for fractures, as it not only provides comfort but also aids in compliance with treatment and rehabilitation.

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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?

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