When assessing a patient with dark skin tones for suspected deep tissue injury, what should the nurse prioritize?

A. Ineffective airway clearance: This diagnosis focuses on obstruction of the airway by secretions or mechanical blockage. While relevant to some respiratory conditions, it does not directly address gas exchange impairment or the client’s anxiety.
B. Risk for infection: This diagnosis addresses potential for infection rather than current acute symptoms. It is preventive in nature and does not target immediate respiratory compromise or emotional distress.
C. Anxiety related to hospitalization: This diagnosis addresses only the psychological component. While the patient is anxious, this alone does not encompass the physiological issue of impaired oxygenation.
D. Impaired gas exchange related to anxiety and respiratory distress: This diagnosis integrates both physiologic and psychological factors affecting oxygenation. Anxiety can exacerbate respiratory distress, and this NANDA diagnosis allows for interventions targeting both improved oxygenation and anxiety reduction.

A. The rule regarding portability of health insurance coverage: This provision addresses the ability to maintain health insurance when changing jobs or coverage, and is unrelated to unauthorized access of patient records.

B. The Security Rule regarding administrative safeguards: The Security Rule focuses on protecting electronic health information through administrative, physical, and technical measures. While security is involved, the primary issue here is unauthorized disclosure, not system safeguards.

C. The Privacy Rule regarding patient authorization and disclosure: HIPAA’s Privacy Rule governs the use and disclosure of protected health information. Accessing a patient’s electronic health record without consent violates the requirement that patients authorize who can view or use their information.

D. The rule concerning breach notification requirements: Breach notification addresses required reporting after a confirmed compromise of PHI. The student’s unauthorized access is a violation of privacy, not a post-breach reporting issue.