A client you are assigned is experiencing arrhythmia. What sign is the client exhibiting?

Choice A reason: Stage 4 pressure injury involves full-thickness tissue loss with exposed muscle, bone, or tendon, as described with a deep depression and visible bone. This severe stage requires aggressive interventions like debridement or surgery. Accurate staging ensures proper wound care, preventing infection and promoting healing in advanced pressure injuries.

Choice B reason: Stage 3 involves full-thickness loss to subcutaneous tissue, not muscle or bone, unlike the described injury with visible bone (stage 4). Misstaging as 3 underestimates severity, risking inadequate treatments like simple dressings, delaying surgical intervention or infection control critical for deep pressure injuries with bone exposure.

Choice C reason: Stage 1 is intact skin with erythema, not a deep lesion with bone exposure, which is stage 4. Misstaging as 1 grossly underestimates severity, neglecting urgent needs like debridement or antibiotics, risking infection, sepsis, or further tissue loss in severe pressure injuries requiring advanced wound management.

Choice D reason: Stage 2 involves partial-thickness loss with a shallow wound, not deep muscle or bone exposure, as in stage 4. Misstaging as 2 risks inadequate care, like topical treatments instead of surgical intervention, delaying healing and increasing complications like osteomyelitis in severe pressure injuries with visible bone.

Choice A reason: Assessment in the nursing process involves collecting subjective and objective data via interviews, physical exams, and observations to inform clinical judgments. This foundational step identifies patient needs, guiding subsequent planning. Accurate data collection ensures comprehensive care, preventing oversight of critical health issues and supporting effective diagnosis and intervention in clinical practice.

Choice B reason: Using problem-solving to prioritize outcomes and develop interventions describes the planning step, not assessment. Assessment focuses on data collection, not goal-setting. Assuming this misaligns with the nursing process, risking premature intervention without thorough data, which could lead to ineffective care plans or missed health issues in patient management.

Choice C reason: Assessing goal effectiveness and adjusting interventions pertains to the evaluation step, not assessment. Assessment gathers data to identify needs, not evaluate outcomes. Misidentifying this risks skipping data collection, leading to incomplete assessments and inappropriate interventions, compromising patient safety and care quality in the nursing process.

Choice D reason: Using clinical judgment to formulate problems is part of diagnosis, not assessment. Assessment collects raw data, while diagnosis analyzes it to identify issues. Assuming this conflates steps, risking incomplete data collection, which could result in inaccurate diagnoses and ineffective care plans, undermining the systematic approach of the nursing process.