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

When providing education to a postoperative client on how to use an incentive spirometer, an accurate step that should be included in the education plan is to instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose ¹⁴. This helps the client to take deep breaths and fully expand their lungs. The other options (Instruct the client to inhale normally and then place the lips securely around the mouthpiece, Encourage the client to perform incentive spirometry 2 to 3 times every 1 to 2 hours, if possible, and When the client cannot inhale anymore, the client should hold his breath and count to 10) are not accurate steps that should be included in the education plan.

A. The client will perform four to five isometric squeezes for 5 to 10 seconds. B. The client will empty her bladder completely each time she voids. C. The client will improve her incontinence within one month. D. The client will stop the ﬂow of urine when voiding.

Correct Answer is A

Explanation

Stress urinary incontinence is the involuntary loss of urine during physical activity such as coughing, sneezing, or exercising. It is often caused by weakness of the pelvic ﬂoor muscles and/or the urethral sphincter. An appropriate outcome for a client with this condition would be to improve the strength of these muscles. Performing isometric squeezes, also known as Kegel exercises, can help strengthen the pelvic ﬂoor muscles and improve sphincter competence. This can help reduce or prevent episodes of incontinence.

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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

A nurse is providing education to a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the education plan?

Correct Answer is A

Explanation

The nurse is identifying outcomes for a client with the nursing diagnosis of Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?

Correct Answer is A

Explanation

The nurse instructs the client on mind-body therapies. Which mind-body therapy is used when the client pictures themselves lying on a beach with the sounds of waves, the cries of seagulls, and the warmth of the sun during periods of stress?

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