A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?

Correct Answer: C

Rationale: The correct answer is C: Observe wound appearance and edges. This is the first intervention the nurse should perform because assessing the wound's appearance and edges provides crucial information about the healing process and any signs of infection. It helps in determining the next steps in the care plan. Reinforcing the dressing (A) and performing dressing changes (B) should come after assessing the wound. Documenting wound characteristics (D) is important but should also follow the initial assessment.

Correct Answer: D

Rationale: The correct answer is D because "Unable to palpate femoral pulse in left leg" is an objective finding that can be measured or observed without interpretation or bias. It provides concrete, measurable information about the patient's condition. Choices A, B, and C are subjective data as they rely on the patient's feelings, emotions, and perceptions, which can vary and are open to interpretation. Objective data is crucial in making accurate assessments and decisions in healthcare.

Correct Answer: A

Rationale: The correct answer is A: Diet and exercise program. This is because a client's diet and exercise program directly impact their physical health and well-being, making it an important factor to consider when determining assessment priorities. Understanding their dietary habits and level of physical activity can help identify potential health risks or areas for improvement. Choices B, C, and D are incorrect because they do not directly relate to the client's physical health and well-being, which are crucial factors in determining assessment priorities. Standing in the community (B) may influence social interactions but does not necessarily impact assessment priorities. Ability to pay for services (C) relates to financial considerations rather than health assessment priorities. Developmental stage (D) may be important for understanding the client's cognitive and emotional development, but it is not as directly relevant to assessment priorities as diet and exercise.

Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying any potential complications that may arise due to the client's condition or treatment. This allows nurses and other healthcare professionals to anticipate and address these complications proactively. A: The client problem - While important, the client problem is usually addressed in the nursing diagnosis rather than the diagnostic statement for a collaborative problem. C: The nursing diagnosis - The nursing diagnosis focuses on the actual or potential health problems that the client is experiencing, which is different from the focus of a diagnostic statement for a collaborative problem. D: The medical diagnosis - The medical diagnosis is the identification of a disease or condition by a healthcare provider, which is not the focus when identifying potential complications in a collaborative problem.

Correct Answer: C

Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem. Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.