A client has a documented stage III pressure ulcer on the right hip. Which nursing diagnosis is most appropriate for this client?
A) Impaired Skin Integrity
B) Risk for Injury
C) Impaired Tissue Integrity
D) Ineffective Peripheral Tissue Perfusion
Answer: C
Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure ulcers result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury and so Risk for Injury does not apply.
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A client has recently undergone an anterior colporrhaphy. Which is the most important discharge instruction that the nurse can provide?
a. "Avoid sexual intercourse for 2 weeks." b. "Call us for fever and pain that does not improve." c. "Sutures will need to be removed in 2 weeks." d. "An ice pack on your incision will help the pain."
The U.S. Food and Drug Administration has
issued a warning for users of antiepileptic drugs. Based on this report, the nurse will monitor for which potential problems with this class of drugs? a. Increased risk of suicidal thoughts and behaviors b. Signs of bone marrow depression c. Indications of drug addiction and dependency d. Increased risk of cardiovascular events, such as strokes
In planning housing for a client being discharged from the hospital, which of the following rationale would appropriately guide the nurse's decision?
A) The nurse knows best and should decide what arrangements are appropriate. B) Clients with mental illness must always live with a family member. C) Most clients prefer an apartment or house. D) Clients usually have no preference about where they will live.
The nurse is calculating the distribution restricted fluids for a patient with acute kidney injury. The patient had a urine output of 200 mL the previous day
What amount of fluid is the patient permitted during the night? Record your answer rounding to the nearest whole number.