The nurse makes the decision to look at alternatives for wound ...

[iveyjurea]

The nurse makes the decision to look at alternatives for wound care with a client who has a stasis ulcer that has been treated over the past 2 weeks. The nurse was hopeful to see some improvement by this time.
 
  This represents which phase of the nursing process?
  1. Diagnosis
  2. Implementation
  3. Evaluation
  4. Assessment

Question 2

A nurse is performing an initial assessment on a new admission. Which of the following is part of the database?
 
  1. Reports from physical therapy the client received as an outpatient.
  2. Documentation of the nurse's physical assessment.
  3. Physician's orders.
  4. A list of current medications.
  5. Information about the client's cultural preferences.
  6. Discharge instructions.

[JaynaD87]

Answer to Question 1

Correct Answer: 3
Rationale: Evaluation is measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement. Activities of evaluation include judging whether goals/outcomes have been achieved and making decisions about problem status. The client's wound is not healing and the nurse decides to modify the nursing interventions. Diagnosis is problem identification. Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Assessment is collecting and organizing data.

Answer to Question 2

Correct Answer: 1,2,4,5
Rationale: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.