Author Question: A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on ... (Read 48 times)

Garrulous · **on:** Jun 25, 2018

A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?

a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently

Question 2

A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel comfortable leaving my children with my parents. Which action should the nurse take next?

a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient's feelings about the child-care arrangements.
d. Call the patient's parents to determine whether adequate child care is being provided.

chevyboi1976 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
The patient's major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The risk for diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is.

Answer to Question 2

ANS: C
Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurse's first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen.