A nurse is assessing an infant during a routine health examination. The nurse notes that the infant's anterior fontanel is sunken. How should the nurse interpret this finding?

Rationale:

A. Assessment is the first step of the nursing process, in which the nurse gathers comprehensive information about the client’s physical health, psychological state, social circumstances, and health history. This step is critical for identifying actual or potential health problems. While assessment provides the foundation for formulating goals, it does not involve setting or planning the goals themselves.

B. Implementation is the phase in which the nurse carries out the interventions developed during planning. During this step, the nurse administers medications, provides education, performs procedures, and collaborates with other healthcare providers. Formulating goals occurs before interventions are initiated, so this is not the correct step.

C. Planning is the step in which the nurse prioritizes the client’s problems or nursing diagnoses, identifies measurable and realistic goals, and determines appropriate interventions to achieve positive outcomes. In this phase, the nurse considers the client’s preferences, available resources, and evidence-based practices. Planning ensures that care is organized, purposeful, and tailored to the client’s unique needs, making it the step in which goals are explicitly formulated.

D. Evaluation is the final step of the nursing process, where the nurse determines whether the client has achieved the desired outcomes. It involves comparing actual results with expected outcomes and deciding whether to continue, modify, or discontinue the plan of care. Formulating goals occurs before evaluation, so this is not the correct step.

Rationale:
A. A client who exercises daily is at low risk for pressure injuries. Regular movement promotes adequate circulation, reduces prolonged pressure on any one area, and maintains skin integrity. Activity is actually protective against pressure injury development.

B. An immobile client is at the greatest risk for pressure injuries. Pressure injuries develop when there is prolonged pressure over bony prominences (e.g., sacrum, heels, hips), which impairs blood flow and leads to tissue ischemia and breakdown. Immobility prevents repositioning, resulting in sustained pressure, decreased perfusion, and eventual tissue damage. Additional contributing factors often include moisture, friction, shear, and poor nutrition, but immobility is the primary and most significant risk factor.

C. A client with a mild headache has no direct risk for pressure injury unless other factors (like immobility) are present. A headache does not affect circulation, mobility, or skin integrity.

D. A client with seasonal allergies is not at increased risk for pressure injuries. Allergies may cause discomfort or respiratory symptoms but do not impair mobility or tissue perfusion in a way that contributes to pressure injury formation.