The nurse identifies the diagnosis of Risk for Injury for a client who is disoriented. Which statement should the nurse identify as an expected outcome for this client's care?
A) The client does not sustain injuries during wanderings.
B) The client maintains continence on four out of five voidings.
C) The client receives culturally appropriate care.
D) The client sleeps through the night and stays awake most of the day.
Answer: A
The client "does not sustain injury during wanderings" is the correct answer because it relates to the diagnosis and is measurable. The client "maintains continence on four out of five voidings" does not relate to the diagnosis. The client "sleeps through the night and stays awake most of the day" does not relate to the diagnosis. The client "receives culturally appropriate care" is an incorrect answer because expected outcomes are unknown and not measurable.
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