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.
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Correct Answer is B
Explanation
The most appropriate statement by the nurse would be to explain the procedure to the client and reassure them that it should not be painful. This can help alleviate the client's anxiety and make them feel more comfortable and informed about the assessment.
Correct Answer is A
Explanation
By offering free occult blood screenings at a community health fair, the nurse is providing illness prevention services. Illness prevention refers to actions taken to prevent the onset of illness or disease. In this case, occult blood screening can help detect early signs of colorectal cancer, allowing for early intervention and treatment to prevent the development of the disease.
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