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
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.

Correct Answer is ["C","D"]
Explanation
If a visitor in the dining room at the hospital has a forceful cough, the nurse should first allow the visitor to continue coughing. Coughing is a natural reflex that helps clear the airway of foreign objects or mucus. The nurse should also assess the effectiveness of the cough. If the cough is weak or ineffective, further intervention may be necessary.
Starting cardiopulmonary resuscitation (CPR) or performing the Heimlich maneuver would only be appropriate if the visitor is choking and unable to breathe. Assisting the client to a sitting position on the floor may not be necessary and could potentially cause harm.
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