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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Based on the comment made by the nurse manager during the staff meeting, this leader can be best identified as a laissez-faire leader. A laissez-faire leader is one who takes a hands-off approach to leadership and allows group members to make their own decisions and determine their own course of action. In this case, the nurse manager is allowing the staff to come to their own decision regarding staff assignments and is not actively directing or guiding the decision-making process.
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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