The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Correct Answer: 1
Rationale 1: Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.
Rationale 2: Diagnosis is identifying the client's response to the problem. Implementation is what the nurse does to help the client reach a goal, and then the goal is evaluated.
Rationale 3: Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.
Rationale 4: The goal of the intervention is evaluated but that is not what is being described in this item..
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