Which is an actual nursing diagnosis?

• A. Acute pain related to tissue injury
• B. Risk for infection related to compromised skin integrity
• C. Risk for falls related to impaired balance
• D. Readiness for enhanced nutrition

Answer: (A)

The key idea here is recognizing an actual nursing diagnosis versus risk diagnoses or health-promotion statements. An actual nursing diagnosis names a current problem that the patient is experiencing, with related factors and evidence.

Acute pain related to tissue injury fits this because it describes a present problem (pain) and includes a related factor (tissue injury) that explains why the pain is occurring. In practice, this would be supported by defining characteristics such as the patient reporting pain, locations, intensity, guarding, or observable distress, guiding immediate nursing actions like pain assessment, administering analgesics, and providing comfort measures.

The other statements describe potential risks or a readiness to improve, not current problems. Risk for infection is about a possible future issue if skin integrity worsens; risk for falls is about a future chance of falling; readiness for enhanced nutrition expresses a goal or positive state rather than an existing problem.