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

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the eﬀectiveness of care (evaluation).

A. Hallucinations at the onset of sleep B. Sleep apnea C. A lack of rapid eye movement (REM) sleep D. The urge to move the legs when trying to sleep E. Sudden attacks of sleep

Correct Answer is ["A","B","E"]

Explanation

During an assessment of a client diagnosed with narcolepsy, the nurse should anticipate the following findings: Hallucinations at the onset of sleep, Sleep apnea, and Sudden attacks of sleep ². These are common symptoms of narcolepsy. The other options (A lack of rapid eye movement (REM) sleep and The urge to move the legs when trying to sleep) are not directly related to narcolepsy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused by the tape used to secure the dressing. In which phase of the nursing process is the nurse working?

Correct Answer is A

Explanation

A nurse is conducting an assessment on a client diagnosed with narcolepsy. The nurse should anticipate which of the following findings? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counselling practice and work full-time. The nurse should realize that this client is demonstrating which aspect of values clarification?

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. What actions should the nurse take first?

A nurse is providing care for a client who has recently been diagnosed with type 1 diabetes mellitus. To focus on aﬀective learning with this client, the nurse should use which of the following interventions?

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

How would a nurse document the condition in which a client has a normal state of awareness?

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+ and equal in radial, popliteal, and dorsalis pedis. What does the number "+3" represent?