A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning?

A) Planning:
The step of the nursing process where the nurse formulates goals to address an identified problem is planning. In this phase, the nurse develops a care plan by setting measurable and achievable goals based on the assessment data. These goals are designed to address the specific health problems identified during the assessment phase. The planning stage also involves determining appropriate interventions and establishing expected outcomes for the patient. It's critical to ensure that the goals are realistic and aligned with the patient’s needs and preferences.

B) Implementation:
Implementation refers to the actual carrying out of the nursing interventions and care plan that were developed during the planning phase. This is when the nurse takes action based on the goals set earlier, such as administering medications, teaching the patient, or performing specific procedures. While this phase is crucial for the success of the care plan, it does not involve the creation of goals, which is the focus of the planning phase.

C) Assessment:
Assessment is the first step in the nursing process. It involves gathering comprehensive information about the patient’s physical, psychological, social, and emotional status. The assessment phase is focused on identifying the patient’s needs, strengths, and problems. While it provides the foundation for formulating goals, it is not the phase where goals are set. Instead, the assessment phase is about collecting data to inform the planning process.
D) Evaluation:
Evaluation occurs after the implementation of interventions. During this phase, the nurse evaluates whether the patient’s goals have been met, partially met, or not met at all. The nurse examines the effectiveness of the care plan and determines if adjustments need to be made. This is not the phase where goals are set; rather, it is a reflective stage where the nurse assesses progress toward achieving the goals established in the planning phase.

A) Granulation tissue forming at the bottom of the wound bed:
Granulation tissue typically forms in wounds that heal by secondary intention. This type of healing occurs when the wound edges are not approximated (e.g., a large or open wound), and new tissue must form to fill the gap. In primary intention healing, the wound edges are well approximated, and granulation tissue is not the hallmark of the healing process, although some may appear early on.

B) Healing of the wound is prolonged:
Wounds healing by primary intention generally heal more quickly than those healing by secondary intention. In primary intention, the wound edges are approximated with sutures, staples, or adhesive, allowing for a faster and more efficient healing process. Therefore, prolonged healing is not expected with primary intention]

C) Skin edges of the wound are sutured closed:
This is the correct finding for a wound healing by primary intention. Primary intention healing occurs when the wound edges are brought together (approximated) and secured with sutures, staples, or adhesive strips. This method promotes faster healing and minimal scarring because the tissue is directly aligned.

D) Wound is contaminated at the time of injury:
Wounds that heal by primary intention are generally clean and not contaminated. If a wound is contaminated or infected at the time of injury, it is more likely to heal by secondary intention, where the tissue must fill in from the base upwards, which takes longer and may result in more scarring.