Nursing process question, help?

[tabz4u2]

The question is

Which part of the nursing process is being used when the nurse is looking at the interview and risk factors to develop a plan of care?

1. Diagnosis

2. Implementation

3. Assessment

4. Evaluation

I put Diagnosis because it said risk factors, and your not assessing the patient, but I'm not quite sure if its right.

A nurse does a wound change and notices that the wound has not been progressing in healing. The nurse decides that another plan of action needs to take place, which part of the nursing process is the nurse showing?

1. Diagnosis

2. Implementation

3. Assessment.

4. Evaluation

This one tricked me but I chose evaluation, because apparently it's not assessment because it was already assessed if they are doing a wound change, and I know it's not diagnosis or implementation? Can someone please help me clarify? I'm not quite sure if evaluation is the right answer. This was a test question that I just took

[lclopez86]

If a goal was not meet in the wound care, the steps of the nursing process should be repeated.Additional assessment data, analysis, or interventions as a result of ongoing assessment may lead to a more satisfactory outcome. Therefore, you would need to reassess the action plan and current situation to come up with a better plan of care.

[nurseprnRN, BSN, RN]

In the first question, you are correct. The data have been collected (looking at the interview + risk factors = assessment) and now it's time to for the nurse to make the nursing diagnosis (es) and develop a nursing plan of care.

In the second one, evaluation is correct. The nurse has noticed that the wound isn't healing. That is, she has made an assessment. She has decided that another plan of action needs to take place; this means she is making an evaluation of the outcome of the previous plan based on her new assessment.

Personally, I think someone might make an argument for it being "implementation," because she has determined that another plan needs to happen (making that determination involved assessment and diagnosis), but there's no action described except the deciding part and you have to go with what they tell you, not let your mind go leaping ahead.

Also, you aren't given any idea that she has formed a new diagnosis. For example, if she had gone from "risk of infection" to "delayed wound healing," and they said that, your choice would be "diagnosis."

Not every test question is a good one. Sometimes when someone writes a question she knows exactly what she means and can be surprised that others took it differently. This is why it's beneficial for an instructor or faculty to work in groups when developing test items. (Can you tell I've spent waaay too much time in working groups developing examinations?) Do your best and move on.

As for you, you need to know the nursing process so well that you feel it in the marrow of your bones. It is what makes us nurses. Good start.

[SWM2009]

I think both your responses are correct.

In the first question, I picked diagnosis for the same reasons you did.

In the second question, evaluation is correct. It is in that step of the nursing process that the nurse would evaluate the effectiveness of the plan of care and change or modify it as necessary.