Your client has a large surgical wound and complains of feeling self-conscious and apprehensive about appearance. Which of the following nursing diagnoses would be most appropriate?
1. Impaired tissue integrity
2. Body image disturbance
3. Hopelessness
4. Impaired skin integrity
Question 2
Your client is at risk for development of pressure ulcers on the heels. Which of the following nursing interventions would be most appropriate?
1. Watch to see if pressure ulcers develop.
2. Avoid massaging over bony prominences because the pressure may increase the risk of pressure ulcer formation.
3. Suspend the heels off the bed.
4. Wash affected areas with hot water and soap to cleanse the skin.