Module 3 - Foundations

When planning initial care for a 16-year-old mother and her newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?

Assess the client's interactions with her newborn.

5 Steps Nursing Process

Assessing, Diagnosing, Outcome Identification and Planning Implementation Evaluation

The nurse formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast AEB client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of:

Etiology

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to client and assess pain.

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders.

QSEN competencies

Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics

SMART

Specific, Measurable, Attainable, Realistic, Time-Bound

A nurse is working with a newly admitted client with diabetes to develop client outcomes. When writing these outcomes, which verb would be appropriate to use in the statement. Select all that apply.

State Explain Demonstrate

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Mark all that apply.

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action?

The nurse should address the concern with the surgeon.

A client who has limited finances and limited capacity for education requires home health care for a chronic illness. For the nurse to provide a high level of care to this client, she must first:

implement critical-thinking skills.