When caring for a client with multiple fractures requiring prolonged bed rest, the nurse knows a priority nursing diagnosis will be:
A)
Risk for Injury related to orthostatic hypotension.
B)
Hypovolemia related to multiple traumatic injuries.
C)
Potential for Impaired Tissue Perfusion related to immobility.
D)
Risk for Social Isolation related to prolonged bed rest.
C
Explanation:
A)
Immobility can contribute to development of DVTs, PEs, edema, and compartment syndrome, all of which could result in impaired tissue perfusion. Options A and D are not as high a priority. Hypovolemia is not caused by immobility.
Application
Analysis/Diagnosis
Physiological Integrity: Reduction of Risk Potential
B)
Immobility can contribute to development of DVTs, PEs, edema, and compartment syndrome, all of which could result in impaired tissue perfusion. Options A and D are not as high a priority. Hypovolemia is not caused by immobility.
Application
Analysis/Diagnosis
Physiological Integrity: Reduction of Risk Potential
C)
Immobility can contribute to development of DVTs, PEs, edema, and compartment syndrome, all of which could result in impaired tissue perfusion. Options A and D are not as high a priority. Hypovolemia is not caused by immobility.
Application
Analysis/Diagnosis
Physiological Integrity: Reduction of Risk Potential
D)
Immobility can contribute to development of DVTs, PEs, edema, and compartment syndrome, all of which could result in impaired tissue perfusion. Options A and D are not as high a priority. Hypovolemia is not caused by immobility.
Application
Analysis/Diagnosis
Physiological Integrity: Reduction of Risk Potential
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