The client who is recovering from severe trauma remains confined to the bed due to a broken leg. The nurse plans care for this client based on a nursing diagnosis of Impaired Physical Mobility. Which intervention should the nurse plan for this client?
1. Monitoring the client's level of consciousness.
2. Monitoring the client for jaundice.
3. Evaluating the legs for heat and swelling.
4. Ensuring a urinary output of 30 mL/hour.
Answer: 3
1. If the client who is recovering has a decreased level of consciousness, the nurse might suspect infection, and the nursing diagnosis would be Risk for Infection.
2. Jaundice relates to liver failure, and is not a part of Impaired Physical Mobility.
3. The client with Impaired Mobility is at risk for developing deep vein thrombosis, which is manifested by heat, swelling, and pain in the lower extremities.
4. Urinary retention is a risk for the client with impaired mobility.
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