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 C

Explanation

Values clarification is the process of assisting another to clarify their own values in order to facilitate decision-making ¹. In this case, the client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counseling practice and work full-time. This demonstrates that the client has prioritized her values and made a decision based on them.

A. "I will restrict my diet to fats and carbohydrates." B. "I will drink 8 to 10 glasses of water every day." C. "I will take the zinc supplement the doctor recommended." D. "I will drink a lot of orange juice and drink milk, too." E. Noncompliance (DASH diet) related to denial of having the disease.

Correct Answer is A

Explanation

This statement by the client would indicate a need for further information about essential nutrition for healing. A balanced diet that includes a variety of nutrients is important for postoperative healing. Restricting the diet to only fats and carbohydrates may not provide all the necessary nutrients for optimal healing. The nurse should provide further education to the client about the importance of a balanced diet that includes protein, vitamins, and minerals in addition to fats and carbohydrates.

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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 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?

Correct Answer is C

Explanation

A nurse is educating a postoperative client on essential nutrition for healing. Which statement by the client would indicate a need for information?

Correct Answer is A

Explanation

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