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

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. This includes instructing the client to report promptly to the practitioner any **increased** redness, swelling, pain, or discharge from the incision or drain sites. These symptoms may indicate an infection or other complication that requires medical attention. The other actions listed are correct and important for promoting healing and wellness after discharge.

A. "Oh, for gosh sakes. it doesn't look that bad." B. "I understand, but you are going to have to look someday." C. "Respect your wish not to look at it right now." D. "You won't be able to go home until you look at it."

Correct Answer is C

Explanation

The appropriate response by the nurse in this situation would be to respect the young man's wish not to look at the wound during dressing changes. This response shows empathy and understanding toward the patient's feelings and emotions and allows him to have control over his own care. It is important for healthcare providers to respect their patient's autonomy and decisions regarding their own care.

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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

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.

Correct Answer is A

Explanation

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

Correct Answer is C

Explanation

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