While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused by the tape used to secure the dressing. In which phase of the nursing process is the nurse working?

Assessment

Diagnosis

Evaluation

Implementation

Answer and Explanation

The Correct Answer is A

The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the eﬀectiveness of care (evaluation).

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Correct Answer is B

Explanation

An appropriate outcome statement for a client with a discharge goal of improved mobility should be specific, measurable, achievable, relevant, and time-bound. In this case, the outcome statement "Client will ambulate without a walker by 6 weeks" meets these criteria. It specifies the desired outcome (ambulating without a walker), provides a measurable goal (6 weeks), is achievable and relevant to the client's goal of improved mobility, and includes a time frame for achieving the goal. The other statements are not specific or measurable enough to be considered appropriate outcome statements.

A. Encouraging the client's participation each time the procedure is performed B. Oﬀering to do the procedure for the client each time it is scheduled C. Teaching the client's support system how to perform the procedure D. Demonstrating the finger stick procedure on the nurse

Correct Answer is A

Explanation

The best way to increase the client's motivation to learn is by encouraging their participation each time the procedure is performed. This can help the client feel more involved in their own care and increase their confidence in performing the procedure. The other options (Oﬀering to do the procedure for the client each time it is scheduled, Teaching the client's support system how to perform the procedure, and Demonstrating the finger stick procedure to the nurse) may not be as eﬀective in increasing the client's motivation to learn.

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While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused by the tape used to secure the dressing. In which phase of the nursing process is the nurse working?

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Naxlex Comprehensive Predictor Exams

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?

Correct Answer is B

Explanation

A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client's motivation to learn?

Correct Answer is A

Explanation

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While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused by the tape used to secure the dressing. In which phase of the nursing process is the nurse working?