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. Ask the patient to try to stand up independently to assess the patient's strength first. This action is inappropriate as it may put the patient at risk of falling or injury. The patient should be assisted rather than asked to stand independently.

B. Remind the patient to look up to ensure good positioning when standing up. This is a correct action. Looking up helps the patient maintain better posture and balance when standing.

C. Allow the patient to dangle at the edge of the bed before standing to assess for feelings of dizziness. This is appropriate as it helps to identify any dizziness or orthostatic hypotension before the patient attempts to stand.

D. Assess the patient for any numbness or tingling in the extremities. This is also appropriate as it helps to identify any neurological issues that could affect the patient's ability to stand and transfer safely.

A. "You sound frustrated, tell me more about this feeling." B. "You remind me of my mother, she is always frustrated when she is ill." C. "I am concerned about your mental health; I will call your family." D. "You need to be more careful after this stroke or you could fall."

Correct Answer is A

Explanation

A. "You sound frustrated, tell me more about this feeling." This response validates the patient’s feelings and opens up a discussion about their emotions, which provides support and helps address their psychological needs.

B. "You remind me of my mother, she is always frustrated when she is ill." This response is not focused on the patient’s needs and shifts attention away from their concerns.

C. "I am concerned about your mental health; I will call your family." While mental health is important, calling the family without first addressing the patient’s immediate concerns might feel intrusive or premature.

D. "You need to be more careful after this stroke or you could fall." This response addresses safety but does not provide emotional support or acknowledge the patient’s feelings of frustration.

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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 teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?

Correct Answer is A

Explanation

The nurse is caring for a patient with a new mobility deficit due to a recent stroke (CVA). The patient states, "I hate not being able to do simple things like walking by myself anymore." Which of the following responses provides the best support for the patient?

Correct Answer is A

Explanation

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