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 D

Explanation

A. "Are you usually anxious about unknown situations?" This question may help understand the client's general anxiety but does not directly address the specific concern related to their current hospital admission.

B. "Do you have any questions about this admission?" This response is practical and offers the client an opportunity to clarify any doubts about the current admission, which might help reduce anxiety.

C. "Are you here for the same reason?" This question is specific to the reason for the admission but may not fully address the anxiety related to the hospital environment.

D. "Can you tell me more about that experience?" This response encourages the client to discuss their previous negative experience, which can help in understanding their anxiety and providing targeted support.

A. Assess the patient for physiological indicators of pain. B. Observe the patient for behavior that is indicative of pain. C. Involve the patient in the pain assessment by asking more direct questions. D. Compare the patient's facial expression to a FACES pain scale.

Correct Answer is C

Explanation

A. Assess the patient for physiological indicators of pain. While assessing physiological indicators (such as increased heart rate, blood pressure, or sweating) can provide clues about pain, these signs are not always reliable and can be influenced by other factors. This option does not directly address the patient’s verbal and non-verbal communication about their pain.

B. Observe the patient for behavior that is indicative of pain. Observing the patient’s behavior can be helpful, but it is not sufficient on its own. The patient’s cultural background may influence how they express pain, and relying solely on observation might lead to underestimating their pain.

C. Involve the patient in the pain assessment by asking more direct questions. This is the best option because it respects the patient’s cultural background and encourages a more accurate and detailed assessment of their pain. By asking direct questions, the nurse can gain a better understanding of the patient’s pain experience and provide appropriate care.

D. Compare the patient's facial expression to a FACES pain scale. Using a FACES pain scale can be useful, especially for patients who have difficulty verbalizing their pain. However, this option does not involve the patient in a more detailed discussion about their pain, which is crucial given the cultural context and the patient’s reluctance to openly admit to pain.

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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 admitting a client to the hospital. The client states, "Hospitals make me anxious ever since my last visit. Which of the following would be the most appropriate response by the nurse?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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