RATIONALE:

The client appears to have a severely injured, possibly broken, foot. Most important findings are those that indicate the severity of the injury. The swelling, delayed capillary refill time, inability to bear weight, and severe pain indicate a serious injury to the foot. These four findings are priority findings when a client has a fractured foot. The client's history of hypertension is important but does not affect the analysis of the situation. The blood pressure may be elevated due to the high level of pain and has not reached dangerous levels, or it is also possible that the client has not yet taken daily medication. The history of hepatitis A as a child is not relevant to the acute care needs.