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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Related Questions
Correct Answer is B
Explanation
Cheyne-Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes ². It is marked by rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea ¹.
Correct Answer is D
Explanation
Heart failure is a condition in which the heart is unable to pump blood effectively, leading to a buildup of fluid in the body. This can result in edema (swelling) and fluid accumulation in the lungs, causing coarse crackles when breathing. The term for this condition is fluid volume excess, which refers to an excessive amount of fluid in the body.
Myocardial infarction is a heart attack, atelectasis is a collapse of lung tissue, and fluid volume deficit refers to a lack of fluid in the body.
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