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 D
Explanation
Developmental testing for kindergarten through third-grade students is an example of primary prevention. Primary prevention aims to prevent disease or injury before it occurs by promoting healthy behaviors and reducing exposure to risk factors.
Correct Answer is C
Explanation
According to Maslow's hierarchy of needs model, physiological needs such as food, water, and shelter are the most basic and fundamental needs that must be met before higher-level needs can be addressed. In this scenario, the nursing diagnosis of Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients addresses a fundamental physiological need and should be identified as the highest priority for this client. The other nursing diagnoses listed address important needs related to safety, self-care, and psychological well-being, but these needs are considered higher-level needs according to Maslow's hierarchy and should be addressed after the client's basic physiological needs have been met.
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