The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?
a. Impaired home maintenance
b. Deficient knowledge
c. Risk for poisoning
d. Risk for injury
ANS: D
The patient's behaviors support the nursing diagnosis of Risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient's home maintenance.
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