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
Explanation
A diuretic is a medication that increases the production of urine by the kidneys. This can help reduce swelling (edema) by removing excess fluid from the body. If a client is prescribed a diuretic for swelling of the lower extremities, the nurse should teach the client that the medication will increase their urinary output. This means that the client will need to urinate more frequently and may produce more urine than usual. The color and odor of the urine may also change, but these changes are not directly related to the effect of the medication on urinary output.

Correct Answer is C
Explanation
The nurse's role in the informed consent process is to witness the client's signature on the consent form. It is the responsibility of the physician performing the procedure to explain the procedure, its risks and benefits, and to obtain the client's consent. The nurse can clarify information and answer questions, but it is not their responsibility to explain the procedure or obtain consent.
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