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
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Nursing Elites

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?

Correct answer: B

Rationale:

2. Which finding is not typically associated with inflammation in a client?

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.

3. What lifestyle habits positively affect skin integrity?

Correct answer: A

Rationale:

4. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

Correct answer: D

Rationale:

5. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

Correct answer: D

Rationale:

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