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 D

Explanation

In this situation, the nurse demonstrated integrity. After realizing the mistake of giving a client who was NPO a morning breakfast tray, the nurse took responsibility for the mistake by notifying the physician and the client, explaining the consequences of the mistake, and documenting the situation in the client's medical record. The other options (Altruism, Human dignity, and Social justice) are not directly related to this situation.

A. Ineﬀective Breathing Pattern as evidenced by cyanotic lips. B. Risk for infection related to recent surgery. C. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds. D. Ineﬀective coping related to depression as evidenced by a suicide attempt. E. Noncompliance (DASH diet) related to denial of having the disease.

Correct Answer is ["A","C","D"]

Explanation

The PED model is a framework for writing nursing diagnoses that stands for Problem, Etiology, and Defining Characteristics. A nursing diagnosis written using the PED model includes a statement of the client's problem (P), the cause or contributing factors of the problem (E), and the observable signs and symptoms that indicate the presence of the problem (D). In this case, options a), c), and d) are examples of nursing diagnoses that demonstrate appropriate use of the PED model. Each of these diagnoses includes a statement of the client's problem, the cause or contributing factors, and the defining characteristics that indicate the presence of the problem.

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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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Correct Answer is D

Explanation

The nurse is using the PED model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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