During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of flushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

Choice A reason: Series of assessments that isolate a client’s health problem is not the best definition of the nursing process. The nursing process is not only a series of assessments, but also a series of actions that include planning, implementing, and evaluating the nursing care. The nursing process does not isolate a client’s health problem, but rather identifies and addresses the client’s holistic needs and responses to health and illness. Therefore, this choice is incorrect.

Choice B reason: Framework for the organization of individualized nursing care is the best definition of the nursing process. The nursing process is a framework that guides the nurse’s decision making and actions in providing individualized nursing care to each client. It involves five steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. It is based on scientific principles, ethical standards, and evidence-based practice. Therefore, this choice is correct.

Choice C reason: Preset formula for the design of nursing care is not the best definition of the nursing process. The nursing process is not a preset formula, but rather a dynamic and flexible method that adapts to the changing needs and situations of each client. It requires critical thinking, creativity, and clinical judgment from the nurse. It also involves collaboration and communication with the client and other members of the health care team. Therefore, this choice is incorrect.

Choice D reason: Method to assure that the physician’s orders are carried out correctly is not the best definition of the nursing process. The nursing process is not a method to assure that the physician’s orders are carried out correctly, but rather a method to provide independent and autonomous nursing care that complements or supplements the medical care. The nursing process reflects the nurse’s scope of practice, responsibility, and accountability for the client’s well-being. It also empowers the client to participate in their own care and achieve their health goals. Therefore, this choice is incorrect.

Choice A reason: This is incorrect because it shows that the wound is healing well. Approximated wound edges mean that the edges are close together and aligned.

Choice B reason: This is correct because it shows that the wound is infected. Yellow, purulent drainage means that the wound has pus, which is a sign of inflammation and bacterial growth.

Choice C reason: This is incorrect because it shows that the wound is healing well. Pink granulation tissue means that the wound has new blood vessels and connective tissue, which fill the wound space and promote healing.

Choice D reason: This is incorrect because it shows that the wound is stable. Sutures in place mean that the wound has been closed with stitches, which hold the edges together and prevent bleeding.