Which of the following is a nursing intervention?
a. The patient will ambulate in the hallway twice this shift using crutches correctly.
b. Impaired physical mobility related to inability to bear weight on right leg
c. Provide assistance while the patient walks in the hallway twice this shift with crutches.
d. The patient is unable to bear weight on right lower extremity.
C
Providing assistance to a patient who is ambulating is a nursing intervention. The statement, "The patient will ambulate in the hallway twice this shift using crutches correctly" is a patient goal. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility.
You might also like to view...
The role of the LPN/LVN in the assessment phase of the nursing process is to:
1. Identify client strengths and promote health maintenance. 2. Collect data and observe and report client status to the RN. 3. Develop an individualized care plan. 4. Observe or measure client responses to nursing interventions.
Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?
A) Plantar grasp B) Step C) Babinski D) Neck righting
The community health nurse is reviewing the needs of vulnerable groups in the community. To focus more specifically, what group would be the best representation of a vulnerable population?
A) Men B) Caucasians C) Heterosexuals D) Individuals with HIV/AIDS
A nurse is caring for a patient whose temperature is 100.2° F. The nurse expects this patient to hyperventilate owing to
a. Increased metabolic demands. b. Anxiety over illness. c. Decreased drive to breathe. d. Infection destroying lung tissues.