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. Hemiparesis: Hemiparesis refers to weakness on one side of the body, which does not fully describe the inability to move only the legs.

B. Hypertonicity: Hypertonicity refers to increased muscle tone or stiffness, not the inability to move legs.

C. Crepitation: Crepitation refers to a crackling or popping sound in the joints, not the inability to move legs.

D. Paraplegia: Paraplegia refers to the paralysis of the lower half of the body, including the legs, which fits the description of the patient’s condition.

A. The client with a left lower extremity fracture. B. The client with a bowel obstruction. C. The client with a skin tear to the upper extremity. D. The client with pneumonia.

Correct Answer is A

Explanation

A. The client with a left lower extremity fracture. Somatic pain is related to damage to body tissues, such as fractures. This type of pain is typically localized and can be acute or chronic.

B. The client with a bowel obstruction. Pain from a bowel obstruction is typically visceral rather than somatic, as it involves internal organs.

C. The client with a skin tear to the upper extremity. While this involves the skin, it is typically considered superficial somatic pain, but the context of the question suggests a deeper musculoskeletal issue.

D. The client with pneumonia. Pain from pneumonia is usually visceral due to inflammation in the lungs.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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