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 D

Explanation

The client would most likely exhibit tachycardia, which is an abnormally fast heart rate. Fever and infection can both cause an increase in heart rate as the body tries to fight oﬀ the infection. Severe pain can also cause an increase in heart rate due to the body's stress response. Therefore, it is likely that the client would have a fast pulse rate, or tachycardia.

A. Call a partial code. B. Call a code. C. Call the physician. D. Call a "slow code."

Correct Answer is B

Explanation

In the absence of an advance directive, the nurse should call a code ³. This means initiating emergency resuscitation measures to try to revive the client. The other options (Call a partial code, Call the physician, and Call a "slow code") are not appropriate in this situation.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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