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

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. This includes instructing the client to report promptly to the practitioner any **increased** redness, swelling, pain, or discharge from the incision or drain sites. These symptoms may indicate an infection or other complication that requires medical attention. The other actions listed are correct and important for promoting healing and wellness after discharge.

A. Clarifying B. Acting C. Prioritizing D. Choosing

Correct Answer is C

Explanation

Values clarification is the process of assisting another to clarify their own values in order to facilitate decision-making ¹. In this case, the client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counseling practice and work full-time. This demonstrates that the client has prioritized her values and made a decision based on them.

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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

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

A nurse is caring for a client in the introductory (orientation) phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

A nurse is taking care of an adult client who throws a temper tantrum because he does not get his own way. Which defense mechanism is the adult client displaying?

The nurse manager has determined that a new staﬀ nurse is demonstrating characteristics of a critical thinker. Which of the following did the manager observe the nurse perform? Select all that apply.

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate?

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

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?

When planning interventions to promote a client's appetite, which of the following would be included in the client's plan?