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
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement by the client would indicate a need for further information about essential nutrition for healing. A balanced diet that includes a variety of nutrients is important for postoperative healing. Restricting the diet to only fats and carbohydrates may not provide all the necessary nutrients for optimal healing. The nurse should provide further education to the client about the importance of a balanced diet that includes protein, vitamins, and minerals in addition to fats and carbohydrates.
Correct Answer is C
Explanation
A client who has accepted the fact that they need bypass surgery for a blocked artery and has been admitted to the hospital is experiencing Stage 2 of illness. Stage 2 is known as the prodromal period, during which the symptoms of illness begin to appear ². The other options (Stage 1, Stage 3, and Stage 4) are not correct.
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