While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working?
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 scenario.
You might also like to view...
A client who frequently exhibits angry outbursts is diagnosed with antisocial personality disorder. Which appropriate feedback should a nurse provide when this client experiences an angry outburst?
A. "Why do you continue to alienate your peers by your angry outbursts?" B. "You accomplish nothing when you lose your temper like that." C. "Showing your anger in that manner is very childish and insensitive." D. "During group, you raised your voice, yelled at a peer, and slammed the door."
A nurse contacts the physician to postpone an angiography if a client has:
A. Been NPO for 1 hour B. The femoral site shaved and cleansed with an antiseptic C. Received Benadryl as a preprocedure medication D. Results of a BUN level of 15 mg/100 ml and a creatinine level of 0.8 mg/ml
A nurse is caring for a client with terminal cancer. The client asks the nurse, "What is the difference between palliative and hospice care?" What is the best response by the nurse?
A) "There is no difference between the two." B) "In palliative care, you must have a terminal illness and have less than 6 months to live. In hospice care you can be in your last stage of illness." C) "Palliative care is focused on attempting to achieve the best quality of life for a client with a serious illness. You may be in any stage of the disease. Hospice care is care and support for a client with less than 6 months to live focused so that the client may live as fully and comfortably as possible." D) "Palliative care can only take place in your home. Hospice care can take place in any care setting."
When monitoring a patient who has diabetes and is receiving a carbonic anhydrase inhibitor for edema, the nurse will monitor for which possible adverse effect?
a. Metabolic alkalosis b. Elevated blood glucose c. Hyperkalemia d. Mental alertness