Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?

pain

skin integrity

fluid volume

knowledge deficit

Answer and Explanation

The Correct Answer is A

A. Pain: Pain is the most immediate concern in this scenario. Managing pain is critical for comfort and preventing further complications.

B. Skin integrity: While skin integrity may be a concern (e.g., pressure ulcers if immobile), it is not the most urgent issue at admission.

C. Fluid volume: There is no mention of dehydration or blood loss. Fluid volume is not the primary concern.

D. Knowledge deficit: While patient education is important, managing pain takes priority over knowledge deficits in acute injuries.

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Correct Answer is C

Explanation

A. CNA (Certified Nursing Assistant): CNAs assist with basic patient care (e.g., hygiene, vital signs) but do not perform assessments or make nursing diagnoses.

B. Technician: Technicians perform specific tasks (e.g., drawing blood, ECGs) but do not analyze patient data for diagnosis.

C. RN (Registered Nurse): The RN is responsible for analyzing and interpreting data, identifying nursing diagnoses, and developing the care plan.

D. LPN/LVN (Licensed Practical/Vocational Nurse): LPNs/LVNs can collect data but cannot make a nursing diagnosis, which is the RN’s role.

A. as difficult to maintain B. as a risk factor C. as a nursing responsibility D. as contributing to the patient's recovery

Correct Answer is B

Explanation

A. As difficult to maintain: This is a subjective statement and not a proper nursing diagnosis.

B. As a risk factor: Bed rest increases the risk of complications such as pressure ulcers, deep vein thrombosis (DVT), and muscle atrophy.

C. As a nursing responsibility: While nurses help manage bed rest, it is not classified as a responsibility but as an intervention.

D. As contributing to the patient's recovery: Although bed rest may be necessary, prolonged immobility can have negative effects, making this statement incomplete.

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Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

Correct Answer is C

Explanation

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

Correct Answer is B

Explanation

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