A client is admitted to the emergency department by ambulance after falling from a moving tractor. The client has large lacerations on the right forearm and hand, and x-rays demonstrate a fractured clavicle
A diagnosis of concussion is made, because the client does not remember what happened or about being transported to the hospital and is confused about present surroundings. Which of the following nursing diagnoses can be made for the client and managed independently by the staff nurse?
1. Mild closed-head injury due to fall from tractor and Fractured clavicle due to fall from tractor
2. 8-centimeter laceration of right forearm and hand due to fall from tractor and High risk for tetanus
3. Bathing/hygiene self-care deficit related to fracture and lacerations and Impaired skin integrity related to accidental injury
4. High risk for tetanus and Risk for infection
ANS: 3
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