Author Question: A client has an external fixation device on his leg due to a compound fracture. The client says that ... (Read 72 times)

s.tung · **on:** Jul 23, 2018

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?

A) Impaired physical mobility
B) Disturbed body image
C) Risk for infection
D) Risk for social isolation

Question 2

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?

A) Ineffective airway clearance
B) Ineffective coping
C) Impaired urinary elimination
D) Risk for body image disturbance

eliasc0401 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: B
The diagnosis of disturbed body image is appropriate for the client because he is worried about the appearance of his legs due to swelling and the external fixation device. There is no mention about impaired physical mobility or risk for social isolation in the client's concern. There may be a risk of infection, but the client does not mention it.

Answer to Question 2

Ans: D

Risk for disturbed body image is the least priority among all the nursing diagnoses mentioned, according to the Maslow's hierarchy. Body image disturbance is not vital for life. Secondly, it is a potential diagnosis, not an actual diagnosis. The other options could be an actual diagnosis present in the client. Ineffective airway clearance is the most important diagnosis because it is vital to life. Impaired urinary elimination is the next most important diagnosis because it is a physiological need. Ineffective coping is a social need, followed by the least important diagnosis of disturbed body image.