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 ["A","C","E"]
Explanation
The manager observed the nurse performing actions that demonstrate critical thinking, including questioning a medication order that does not appear to meet the client's needs for pain management, exhibiting a willingness to try alternate methods of addressing a client's care needs, and listening to empathy to a client who has recently been diagnosed. These actions show that the nurse is able to think critically and make informed decisions based on the needs of the client.
Correct Answer is ["A","D"]
Explanation
A test to determine the amount of residual urine is used to measure the amount of urine that remains in the bladder after voiding. This assessment can be used for several reasons, including to determine the need for medications that can help improve bladder emptying and to evaluate the amount of retained urine after voiding. Retained urine can increase the risk of urinary tract infections and other complications. This test is not typically used to evaluate fluid volume status, glomerular filtration rate, or the extent of renal failure.
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