The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?
Risk for Injury
Altered Tissue Perfusion
Impaired Tissue Integrity
Impaired Skin Integrity
The Correct Answer is D
A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reflects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse would question the discharge of a client to be cared for by the family if the client and family lack knowledge of the treatment regimen. It is important for the client and family to have a good understanding of the treatment regimen in order to provide safe and effective care at home. The other options (The client will need sterile dressing changes, The client will be discharged with a feeding tube, and The client will be receiving IV medications by home health nurses) are not situations that would necessarily prevent discharge to be cared for by the family.
Correct Answer is B
Explanation
The most appropriate response by the nurse would be to explain to the client that antibiotics have no effect on viruses. Upper respiratory infections, such as the common cold, are caused by viruses and therefore antibiotics would not be effective in treating the infection. It is important for the nurse to educate the client about the appropriate use of antibiotics and to address any misconceptions they may have.

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