the nurse notices a new area of skin breakdown near the site of a dressing this would be an example of which phase of the nursing process

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?

A. Diagnosis
B. Assessment
C. Implementation
D. Evaluation

Correct answer: B

Rationale:

2. A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. What statement by the client indicates a correct understanding of the teaching?

A. "I should choose red meat instead of poultry."?
B. "I should avoid eating liver and other organ meats."?
C. I can drink only white wine."?
D. "I will need to limit the number of fruit servings each day."?

Correct answer: B

Rationale:

3. The client states, â€œthe doctor says I am nearsighted. I do not get it.â€ What would be the best response by the nurse?

A. I am sorry you did not understand. Would you like a different doctor?
B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
C. You will need to have glasses.
D. This means you wonâ€™t ever need glasses.

Correct answer: B

Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.

4. What should be done immediately after an ankle injury?

A. Immobilize, heat, compress, and elevate the ankle
B. Rest, ice, compress, and lower the ankle
C. Rest, ice, compress, and elevate the ankle
D. Rest, incubate, confine, and lower the ankle

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.