This topic contains a solution. Click here to go to the answer

Author Question: The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis ... (Read 51 times)

lb_gilbert

  • Hero Member
  • *****
  • Posts: 588
The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client?
 
  1. Altered Tissue Perfusion
  2. Impaired Skin Integrity
  3. Impaired Tissue Integrity
  4. Risk for Injury

Question 2

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected?
 
  1. Clean areas of granulation tissue
  2. Exudate in the bottom of the wound
  3. A pus-coated area on the side of the wound
  4. Intact skin at the edge of the wound



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

mmj22343

  • Sr. Member
  • ****
  • Posts: 297
Answer to Question 1

Correct Answer: 3
Rationale 1:Although it is true that pressure ulcers result from altered tissue perfusion, the diagnosis problem statement Impaired Tissue Integrity is more specific.
Rationale 2: Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue.
Rationale 3: Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria for using the NANDA nursing diagnosis problem statement Impaired Tissue Integrity.
Rationale 4: This client has already suffered injury, so this is not a Risk for Injury situation.

Answer to Question 2

Correct Answer: 1
Rationale 1: Microorganisms that are most likely to be responsible for wound infections live in viable tissue such as granulation tissue.
Rationale 2: Exudate contains a variety of components and will not give a good indication of what is causing the infection.
Rationale 3: Pus contains a variety of components and will not give a good indication of what is causing the infection.
Rationale 4: The skin at the edge of the wound contains skin organisms that may or may not be present in the wound itself.




lb_gilbert

  • Member
  • Posts: 588
Reply 2 on: Jul 23, 2018
Great answer, keep it coming :)


okolip

  • Member
  • Posts: 362
Reply 3 on: Yesterday
Excellent

 

Did you know?

Everyone has one nostril that is larger than the other.

Did you know?

Amphetamine poisoning can cause intravascular coagulation, circulatory collapse, rhabdomyolysis, ischemic colitis, acute psychosis, hyperthermia, respiratory distress syndrome, and pericarditis.

Did you know?

To prove that stomach ulcers were caused by bacteria and not by stress, a researcher consumed an entire laboratory beaker full of bacterial culture. After this, he did indeed develop stomach ulcers, and won the Nobel Prize for his discovery.

Did you know?

Patients who have been on total parenteral nutrition for more than a few days may need to have foods gradually reintroduced to give the digestive tract time to start working again.

Did you know?

The toxic levels for lithium carbonate are close to the therapeutic levels. Signs of toxicity include fine hand tremor, polyuria, mild thirst, nausea, general discomfort, diarrhea, vomiting, drowsiness, muscular weakness, lack of coordination, ataxia, giddiness, tinnitus, and blurred vision.

For a complete list of videos, visit our video library