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 A

Explanation

The nurse should document the client's condition as anorexia. Anorexia refers to the loss of appetite or desire to eat. In this case, the client is reporting a loss of appetite following a prolonged illness, which would be accurately described as anorexia.

A. Extinguish the fire if possible. B. Rescue the client from immediate danger. C. Activate the fire alarm system. D. Confine the fire by closing doors and windows.

Correct Answer is B

Explanation

The first action the nurse should take in this situation is to rescue the client from immediate danger. This means ensuring that the client is safely removed from the room and away from the fire. The safety of the client is the top priority in this situation. Once the client is safe, the nurse can then take further actions such as activating the fire alarm system and attempting to extinguish the fire if possible.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?

Correct Answer is A

Explanation

A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. What actions should the nurse take first?

Correct Answer is B

Explanation

Which of the following principles does the nurse use in selecting interventions for the care plan?

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.

A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." One of the following statements demonstrates that the nurse appropriately evaluated this goal.

The nurse educator provides developmental testing for kindergarten through third-grade students. Which level of prevention is the nurse performing?

Which one of the following roles of the home health care nurse illustrates the role of coordinator of services?

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?

A client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counselling practice and work full-time. The nurse should realize that this client is demonstrating which aspect of values clarification?

A client has been prescribed a clear liquid diet. What food or ﬂuids will be served?