NR446 collaborative Healthcare

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I will need help answer this questions.

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1.The unlicensed assistive personnel (UAP) calls the nurse to the room of q client who ws
admitted to the psychiatric unit yesterday for sever panic attacks. The UAP says, “Look the client
is curled up like a ball, trembling, shaking, and breathing fast. I can’t take the vital signs. The
nurse helps to calm the client.
a. Have the UAP take the client’s vital signs and assist the client into bed
b. Hold the client in a close embrace while the UAP takes the vital signs
c. Determine what the client was thinking just before the panic attack started
d. Say to the client, “You worked yourself up needlessly. There’s nothing to be anxious about. “
2. Two nurses have come to the nurse manage to report that they suspect the charge urse of
diverting narcotics with supporting information. They are very distraught to report this as the
charge nurse has been on the unit for many years and gets along well with everyone. However,
ethically, they feel it is the right thing to do.
a. Schedule a meeting with the charge nurse and the two nurses together to discuss the
allegations.
b. Send an email to the Charge nurse demanding to know why narcotics are being stolen
c. Ask the nurses to provide the proof needed to confront the charge nurse about the
allegations.
d. Meet with the charge nurse to discuss the issue but do not divulge the source of the
information.
3. The nurse preparing to undergo an elective cholecystectomy. In hich order should the
following preoperative steps be performed?
Items to be ordered.
1. client signs consent form
2. Healthcare provider explains procedure to client
3. Consent form is placed in chart
4. preoperative medication is administered
5. Witness Signs consent form
4. A client with diabetes presents to the clinic. Their glycosylated hemoglobin (HbA1C) is 9.4 %.
The client has difficulty adhering to the prescribed diet and asks for suggestions.
Which dietary choices should the most appropriate for the nurse to recommend? Select all that
apply
a. Spaghetti with meatballs and parmesan cheese ,steamed broccoli ,raw carrots ,and a glass of
water
b. Hamburger with roll and a slice of cheese, curly French fries, an orange, and a glass of milk
c. one fish fillet, rice pilaf, cream corn ,one slice of watermelon, and a glass of soda
d. Baked ravioli, sausage, and mixed green salad, a piece of cherry pie, and a saucer water
e. Ham sandwich with a slice of cheese, a banana, and iced tea with low calorie sweetener
5. The nurse assesses a client diagnosed with bipolar disorder managed with lithium based on
the clients assessment the provider requests laboratory evaluation. What assessment finding by
the nurse supports the finding of the providers request?
a. Describe a headache two days ago for which pain medication helped
b. Reports having two loose stools in the past four days
c. Report sleeplessness and tremors to both hands that started yesterday
d. Expresses no episodes of manic behavior in the past six months
6. A student in the local high school attempted suicide because of being bullied by other
students in the school; the student is now in a coma. the community health nurse plans a
presentation about bullying to students and teachers at the school what is most important for
the nurse to include in the presentation? Select all that apply
a. When students have low self-esteem, they are more apt to react negatively to bullying.
b. Students who bully other students usually lack empathy and are aggressive.
c. Bullying helps students grow into strong adults who can manage tough situations.
d. Bullies are often observing violent or abusive behavior at home.
e. Victims of bullying frequently experience social isolation.
7. A 46-year-old client presents to the emergency Department following a motor vehicle
accident. Complete the following sentences by choosing from the list of options the nurses
expects the client is experiencing
1. Alcohol withdrawal, an anxiety attack, excruciating pain, compartment syndrome
2. A benzodiazepine, additional pain, medication emergency surgery, and anti hypertensive
8. The nurse receives change of shift report of four clients on a maternity unit. Click to identify
the client the nurse should assist first.
Room 302 -client with cervical radium implant in place who has been crying in her room
Room 303-client who presents with 5/10 pain after abdominal hysterectomy
Room 305 -client with a possible ectopic pregnancy who reports intense shoulder pain
Room 306-client in the 15th registration who has uterine cramping and spotting
9. The nursing supervisor calls a nurse who is off shift at home and states we are asking all
available staff to come into work immediately we really need you are you able to come in what
hospital plan is the most likely reason for the supervisors call to the nurse?
a. Infection control plan
b. Disaster plan
c. Client elopement plan
d. Unit staffing plan
10. A nurse works in a mobile clinic providing human immunodeficiency virus(HIV) screening to
residents to various neighborhoods . Today, a client has tested positive for HIV and says to the
nurse, “ I kind of knew I was positive, but I just wanted to be sure. I know who I got it from too!
Women are so deceiving. Anyway, I already took my revenge as I already slept with several
women deliberately. What question is most important for the nurse to ask the client?
a. Did you use condoms when you had sexual intercourse with these women?
b. Do you know that it is a crime to knowingly infect women with HIV?
c. Can you locate all the women with whom you have sex while infected?
d. Do you know you are just as deceiving as the woman who infected you?
11. The nurse receives a prescription to administer 100 mL of IV fluids at 125 mL/hr . the bag is
hung at 0900. at what time should the nurse hang on your back answer in military time without
a colon. _______
12. A hospitalized client develops watery incontinent diarrhea. a stool culture confirms a
diagnosis of Chloridoids difficile which action should the nurse take? Which actions should the
nurse take? Select all that apply
a. Place the client on contact precautions in a private room
b. Clean all equipment that has been in the room with bleach wipes
c. Question the health care providers orders which do not include antibiotics
d. Wash hands with soap and water after touching anything in the room
e. performs hand hygiene with a waterless hand product when leaving room
13. A pediatric client sustains an injury and is prescribed pain medication. the nurse administers
morphine sulfate as prescribed. when checking on the client 10 minutes after the opioid, the
client’s respiratory rate is 6 breaths per minute. the rapid response team is called to the unit
and naloxone is prescribed at 0.1 mg/kg. the client weighs 66 pounds. the medication is
available in 400 micrograms/mL. how many milliliters (mL) of naloxone should the nurse
administer? round to the nearest hundredth.
________
14. A pregnant client presents in active labor at 29 weeks gestation. the labor is controlled with
tocolytic medications. the client asks when they will be able to go home. which response by the
nurse is most accurate?
a. Your length of a stay depends on our ability to stop your labor until full term
b. After the baby is born you will be charged to go home with the baby
c. Whenever the healthcare provider says that you are ready to go home
d. when we can stabilize your preterm labor and arrange home health visits
15. A client presents to the emergency department (ED) reporting vomiting, diarrhea, fatigue,
and abdominal pain. the client is diagnosed with hyponatremia, dehydration, and
gastroenteritis of another origin. in addition to normal saline intravenous fluids which diet
should the nurse anticipate?
a. High-fat diet
b. high-fiber diet
c. low-sodium diet
d. non-diary diet
16. The nurse provides teaching to the parents of a 7-year-old child who just had a cast applied
for a fractured arm with the wrist and elbow immobilized. Which instruction to the nurse
include in the teaching?
a. Evaluate the casted arm daily when resting and when sitting up
b. Swelling of the fingers is to be expected for the next 48 hours
c. Allow the affected limit to hang down for one hour each day
d. immobilized the shoulder to decrease pain and arm
17. 68 year old client with history of DM type 2 ,HTN, CAD, previous alcohol abuse, current 2
PPD smoker admitted for glucose control and infected left foot wound requiring IV antibiotics.
being discharged to home where he lives with his adult son education provided to client and his
son on glucose monitoring insulin administration oral medication low sodium diabetic diet and
wound care follow up appointment at diabetes and nutrition care clinic in one week to assess
wound healing and review clients home glucose monitoring log client already has glucometer
and glucose monitoring supplies at home wheelchair and Walker have been delivered to the
home prescription ready for pickup in outpatient pharmacy.
Education Note: return demonstration of home glucose monitoring
Observe client performing steps as follows:
1. Wash hands with soap and water
2. Dried hands with a clean towel
3. Pricked the pad of the left middle finger with a Lancet
4. Touched the edge of the test strip to the drop of blood
5. insert the test strip into the glucometer
6. Waiting for reading
The following says questions are part of an unfolding case study.
The home health nurse cares for a client after discharge from an acute care facility the nurse
observes that the client returned demonstration of home glucose monitoring records the steps
in the order completed in the electronic health record and reviews the procedure with the
client.
For each potential response by the client the nurse clicks to specify if the response is indicated
or not indicated.
Nursing Response
-have you run out of hand sanitizer and alcohol wipes
– your hand hygiene was performed just like I showed you
-lets review the best way to use the Lancet to draw blood
-it is better for your hands to dry by gently waving them
-the blood needs to drip to the strip to avoid contamination
-the test strip needs to be inserted before the finger stick
18. The nurse speaks with the client on the telephone on 3/8 to provide the safest and most
effective care to the client how should the nurse respond?
a. the social worker will secure a taxi voucher for you to come to the appointment
b. Do you have Internet access we can complete your visit on your telehealth platform
c. When is a good time for the home health nurse to schedule a visit with you
d. We have some openings next week if you will have transportation then
19.
68 year old client with history of DM type 2 ,HTN, CAD, previous alcohol abuse, current 2 PPD
smoker admitted for glucose control and infected left foot wound requiring IV antibiotics. being
discharged to home where he lives with his adult son education provided to client and his son
on glucose monitoring insulin administration oral medication low sodium diabetic diet and
wound care follow up appointment at diabetes and nutrition care clinic in one week to assess
wound healing and review clients home glucose monitoring log client already has glucometer
and glucose monitoring supplies at home wheelchair and Walker have been delivered to the
home prescription ready for pickup in outpatient pharmacy.
The home health nurse visits the client and the client’s home on 3/10 complete the following
sentences by choosing the list of options. the nurse expects the client is experiencing and
prioritizes the assessment of the client.
1.
2. -blood glucose
-wound
-vital signs
-HbA1C
20. The home health nurse visits the client and the client’s home on 3/10 and recognize that the
client is experiencing multiple complications of diabetes mellitus complete the following
sentence by choosing the list of options the client and our symptoms of diabetic ketoacidosis
that contribute to a self care deficit.
1.-vision impairment
-urinary frequency
-fruity breath
-increasing pain
2.-poor diet
-confusion
-noxious order
-polypharmacy
the findings that is of most importance immediate concern to the nurse. Select your answer by
clicking the desired location on the image below to move a pin click another location on the
image to remove a pin click it once.
3/10- glucometer in the cupboard OK easy
Point of care glucose my French range 70-100mg/dL
result 392
22. The home health nurse plans the client’s care for the remainder of the home visit on 3/10.
Select three actions the nurse should prioritize today.
A. Reinforce education on insulin self-administration.
B. Coordinate admission to an assisted living facility.
C. Stabilize the client’s blood glucose levels.
D. Contact the health care provider to reduce polypharmacy.
E. Address the client’s increased heart rate and blood pressure.
F. Perform wound care and administer antibiotics.
G. Contact the son to discuss his neglects of the client.
H. Reinforce education on a low-sodium diabetic diet.
I. Obtain functional glucose monitoring supplies.
J. Call adult protective services to report neglect.
23. A client diagnosed with post-traumatic stress disorder is being admitted to the inpatient
psychiatric unit due to suicidal thoughts. As the nurse completes the admission, the client
reports an inability to sleep due to recurrent nightmares of the traumatic event.
When the nurse asks the client about the event, what situation is the client likely to describe?
A. Smoking marijuana as a teenager
B. Speaking in public for the first time
C. Fatal shooting of family members
D. The wedding of the client’s first child
A woman in labor has just received an epidural block.
What is the most appropriate initial nursing action?
A. Monitor the maternal pulse for possible bradycardia.
B. Limit parenteral fluids and maintain client’s NPO status.
C. Monitor the maternal blood pressure for possible hypotension.
D. Monitor the fetal heart rate for possible tachycardia.
25. a nurse monitors a client experiencing a sudden onset of acute abdominal pain and frank
vaginal bleeding.
Which additional assessment finding is most concerning to the nurse?
A. Late decelerations
B. Moderate variability
C. Accelerations with fetal movement
D. Average FHR of 126 beast/min
26.The nurse assesses a client 12 hours post vaginal birth and finds a boggy uterus that is
displaced above and to the right of the umbilicus Which immediate nursing action is most
appropriate?
A Evaluate and document the lochia.
B Assess the blood pressure and pulse.
C Assist the client in emptying her bladder.
D Notify the health care provider of potential hemorrhage.
27Nursing Notes
Laboratory Results
MAR
Lab
Reference
Range 8/8, Glucose 70-100
Regular Insulin subcutaneous AC
and HS
Blood glucose < 70, initiate hypoglycemia protocol Blood glucose 70-130, give 0 units Blood glucose 131-180, give 4 units Blood glucose 181-240, give 8 units Blood glucose 241-300, give 10 units Blood glucose 301-350, give 12 units Blood glucose 351-400, give 16 units Blood glucose > 400, give 20 units
and call provider
30
31
1705
4 units
Given
0610
8 units
Given
Client asking when they will receive their breakfast tray. Trays have not arrived
from the kitchen. Call placed to kitchen and tray carts should arrive “soon.
A client’s roommate calls the nurse to request assistance for the client at 0715 When the nurse
enters the room and assesses the client, which client cues is the nurse most likely to find? Select
all that apply.
A client’s roommate calls the nurse to request assistance for the client at 0715
27.When the nurse enters the room and assesses the client, which client cues is the
nurse most likely to find? Select all that apply.
A Excessive thirst
B Bradycardia
C Slurred speech
D Diaphoresis
Confusion
F pallor
28.The nurse cares for an infant whose cleft lip was recently repaired What are important aspects
of this infant’s postoperative care?
A Supine and side-lying positions, postural drainage, and arm restraints
B Arm restraints, postural drainage, and mouth irrigations
C Mouth irrigations, prone position, and cleansing of suture line
D Cleansing of suture line, supine and side-lying positions, and arm
29 A client admitted with exacerbation of emphysema is now ready for discharge. The client is
dressed and sitting comfortably in a chair reading the newspaper while waiting for their ride. The
nurse takes a set of vital signs: blood pressure 132/82 heart rate 79, respiratory rate 20, and Sp02
86% on room air Which initial action by the nurse is most appropriate?
A Remove the pulse oximeter probe and place it on the client’s toe
B Reposition the pulse oximeter probe and recheck saturation level.
C Place nasal cannula on client and turn flow meter to 2 liters/minute.
D Call the physician and report the client’s oxygen saturation level.
•
30 client is admitted O the medical unit from home and is found to have a Stage 3
pressure injury Which image best represents this pressure injury? (Injury photos)
31. The health care provider prescribes hydromorphone 1 mg to be administered
intravenously every 3 hours for pain. In the medication system is hydromorphone 4
mg/mL. How many milliliters (mL) should the nurse administer when the client requests
a
dose? Do not round
32.A client was admitted yesterday following an all-terrain vehicle accident. The client
sustained a distal tibia fracture which required surgery. The client is postoperative
day one following an open reduction and internal fixation of the right tibia fracture.
Postoperative orders are documented in the electronic health record. The client requests
pain medication one hour after the last dose, stating, “It hurts really bad, way more than
yesterday.” The nurse checks the client’s toes for movement. The client cannot move his
toes, which appear dusky and are cool to the touch Which intervention should the nurse
implement first?
A Call the health care provider immediately.
B Elevate the leg on pillows above heart level.
C Apply a new bag of ice to the affected area.
D Administer the prescribed pain medication
33. The nurse cares for a young Chinese client who is determined brain dead after a
tragic accident. The health care team plans to speak with the parents about donation of the
client’s organs. The nurse tells the team that this is not a good plan What is the reason for the
nurse ‘disagreement with the plan?
A The client’s parents do not speak English and may not understand the request.
B Keeping the deceased body intact is a fundamental belief of this family’s culture
C The nurse is not a strong supporter of removing clients’ organs after death.
D The timing is not right as the parents are grieving the inevitable loss
34.The nurse provides discharge teaching to an older adult client. The client appears distracted
and at times there is a confused look on the client’s face. The client says,”| don’t understand a
word you’re saying.” The nurse self-assesses and determines that a different communication
approach is needed. C How should the nurse change the communication approach to ensure the
client understands the teaching? Select all that apply
A Use correct gestures because the nurse used gestures at the wrong
time and in an inappropriate way.
B Use proper pacing because the nurse spoke rapidly and didn’t always
speak the words clearly.
C Change time of teaching because the client was watching television
during the education session
D Use correct gestures because the nurse used gestures at the wrong time and in an
inappropriate way.
E Use proper pacing because the nurse spoke rapidly and didn’t always
B speak the words clearly.
Change time of teaching because the client was watching television during the education
session
Use clarity and brevity because the nurse spoke in long sentences and used several filler
words
E Change the facial expression because the nurse’s words did not always match the facial
expression
35. New prescription: Enalapril 5 mg PO daily, Fill. 30 tabs
Refill prescription: Bupropion XL 150 mg PO daily, Fill: 30 tabs
A 61-year-old client self-monitors their blood pressure and brings a log to their follow-up
appointment. How should the nurse interpret the client’s data? Select all that apply.
A The client will likely continue taking this medication at the current dose.
B The client no longer requires blood pressure medication
C The medication is not providing appropriate blood pressure control.
D The client may require the medication less frequently
E The client may require a smaller dose of the medication
The medication is providing excellent blood pressure control.
F The provider may discontinue this medication and try a different one
H The client is experiencing a medication interaction
36.Based on the client’s statement, which nursing actions are priority? Select all that
apply.
A Inquire if the client has a plan for ending his life
B Tell the client that suicide is very selfish and cowardly.
C Remove all items from the meal tray that can cause harm.
D Remind the client that his kids will grow up without a father.
E Ensure the client is placed on suicide watch.
37. A transgender client who was assigned female at birth receives hormones as part of
their gender-affirming care. The hormones have not sufficiently reduced breast tissue size
and the client is scheduled for a breast reduction Which statement by the client indicates
an accurate understanding of the reason for this surgery?
A This single surgery will complete my transition from female to male
B “Removing my breasts will ensure that my other genitals can grow.”
“In order to have a successful transition, I need to have flat breasts
“I need to have my breasts removed since the medications were not
38.Nursing Notes
MAR
0850
45-year-old client 2-days post-op bowel repair, Midline abdominal incision
closed with staples. NG to left naris to continuous wall suction. Strict NPO
TPN infusing to right arm PICC line.
0900 Abdominal dressing due. to be changed per wound care orders
0940 LPN into client room, repeat focused assessment completed. Client
complains of pain at incision rated 5/10 and mild nausea. Abdominal dressing
changed as ordered. Incision assessment remains unchanged. Abdominal
binder reapplied. NG depth verified by measurement at naris, tape secure,
remains connected to continuous suction, Client educated on incentive
spirometer use with return demonstration by client. BMP results analyzed to
confirm TPN formula. Medications administered per MAR. Plan of care
discussed with client.
A 45-year-old client is two days postoperative. For each action performed by the licensed
practical/vocational nurse (LPN/LVN), click to specify if the action is within or outside
the LPN/LVN scope of practice.
LPN Completed Task
Within Scope
Outside Scope
Verify NG measurement depth
Morphine administration
Apply abdominal binder
Incentive spirometer education
Evaluation of BMP lab results Abdominal dressing change
Plan of care education
38. nurse on the oncology unit who was known to be uninvolved in any aspect of the
unite governance and not seen as a leader is noted to be energized and empowered
lately. The nurse. just shared an article in the staff meeting on a new evidence-based
practice for clients undergoing a surgical procedure.
What specific occurrence is the most likely contributor to the nurse’s increased leadership
stance?
A The nurse decided to be in control on the unit to avoid the talk about poor leadership.
B Wants a transfer to another unit and believes that being active on this unit will achieve
that goal.
C The manager’s annual evaluation of the nurse gave the nurse only a 1% raise in salary.
D Was asked to work on the shared governance council and is actively participating
.practice for clients undergoing a surgical procedure.
What specific occurrence is the most likely contributor to the nurse’s increased?
leadership stance
39
40.The nurse prepares to initiate continuous enteral tube feedings for a client.
Which client is properly positioned for continuous enteral tube feedings? (Refer to pics)
41client with a cardiac valve disorder presents to the Emergency Department
reporting chest pain beneath the left clavicle. The client is suspected of experiencing
pericarditis Which assessment data should the nurse expect?
A An annoying nonproductive cough lasting a week
B An elevated C-reactive protein laboratory value
A friction rub heard at the lower left sternal border
D An oral temperature of 101.2 °F (38.4 °C)
42.5/4
1815
Client reports 7/10 pain to surgical site, Administered IV pain medication an assisted client with
positioning and ice application. Client reports some nausea and would like to eat dinner tray a
little later.
After receiving report for the 1900 shift, the nurse assesses a client complaining of pain and
requesting pain medication
Medication
5/4
0550 Given
1025 Given
1400 Given
Morphine 4 mg IV every 4 hours PRN pain
Ketorolac 15 mg IV every 6 hours PRN pain
0800 Given
1610 Given
For each nursing action, click to specify if the action is appropriate or inappropriate.
Nursing Actions
Nursing action
ask the client what medication
they last received
administer morphine as
prescribed
call the previous nurse to verify
then documents administration
for them
discuss the situation we did
nurse manager
appropriate
inappropriate
45. The nurse cares for a 2-year-old who has cystic fibrosis. The client is small for their age.
What dietary suggestions can the nurse recommend to the child’s parent to enhance?
their growth?
A High-protein, high-calorie meal with skim-milk milkshakes between meals.
B Low-fat, low residue, and high-potassium diet with juices often.
C Low-carbohydrate, soft diet with no extra sugar products
D High-fiber, high-fat diet with extra water between meals.
46. The nurse assesses a client who lost significant blood and requires blood transfusion.
Which cue in the client’s history leads the nurse to believe that another means of treatment might
need to be established?
The client reacted to a previous blood transfusion.
B The client’s blood type is O-positive
C The client is of the Jehovah’s Witnesses faith.
D The client attends and is active in a Baptist church
47.A client comes to the outpatient endoscopy center for a screening colonoscopy to
be done using conscious sedation. The client asks, “What is conscious sedation?” The nurse’s
response is based on which information?
A The client will be awake and able to talk during the entire procedure
B The client will maintain spontaneous respirations during the procedure.
C Clients are completely unconscious during the entire procedure.
D Most clients require intubation for a short time during the procedure
48. client has a blood pressure reading of 168/90 mmHg and a radial pulse of 82 bpm What is
this client’s pulse pressure? Round to the nearest whole number .mmHg
49. The nurse knows that working with informatics and technology every day provides
effective health care to clients.
What are the advantages of using informatics in health care delivery? Select all that apply.
A Increased client anonymity and confidentiality.
B Reduced need for nurses in acute and urgent care units
C The ability to achieve and maintain high standards of care.
D Access to standardized plans of care for many health problems.
Improved communication among the client’s health care team.
50.Every morning, a client performs a spiritual ritual of burning candles, placing a shawl over
the head and praying. The nurse determines that the safety of the client and the roommate are not
at risk What assessment of the environment lets the nurse know that the client is practicing the
ritual in a safe manner
A Lights one candle at a time instead of all at the same time.
B Uses flameless candles instead of lighting real ones
C Lights the candles and burns them for only five minutes.
D Burns the candles in the bathroom to avoid bothering the roommate
51.When examining a client who gave birth 5 hours ago, the nurse finds that the client
has completely saturated a perineal pad within 15 minutes.
Which nursing action is the priority?
Answers: A – D
A Begin intravenous fluid infusion.
B Assess the client’s vital signs.
C Call the health care provider.
D Massage the client’s fundus.
52.Nursing Notes.
Health History
2/9
Client in OBGYN clinic with reports of breast changes. Client states she felt a small firm
area in the upper area of her right breast about 8 months ago.
Client states in the past 2 months the firm area has become larger, a bit red, and the
skin near the firm area is dimpling. Client denies any pain in her breast or axillary area:
The following six questions are part of an unfolding case study.
A 62-year-old client presents to the care clinic with acute symptoms.
Complete the following sentences by choosing from the lists of options.
The nurse anticipates the provider will first recommend a(n) 1) to further evaluate the
client’s complaints. If malignancy is suspected. the nurse anticipates the provider will
then recommend to confirm the diagnosis.
Nursing Notes.
Health History
Medical History
Obesity
Metabolic Syndrome
Osteoporosis
Surgical History
• Laparoscopic cholecystectomy-age 36
Obstetric History
Nulligravid
Menopause-age 51
Social History
• Smoking 1 ppd x 38 years
Medications
Alendronate 10 mg PO daily
Multivitamin PO daily
Ibuprofen PO PRN
Answers 1 – 2
1. Select answer choice
mammogram
MRI imaging
core biopsy.
genetic testing
2. Select answer choice
needle-aspiration biopsy
hormone receptor testing
lymph node biopsy
BRCA1 evaluation
53.Nursing Notes.
Health History.
Diagnostic Results
Health History
2/9
Client in OBGYN clinic with reports of breast changes. Client states she felt a small firm
area in the upper area of her right breast about 8 months ago.
Client states in the past 2 months the firm area has become larget, a bit red, and the
skin near the firm area is dimpling. Client denies any pain in her breast or axillary area.
2/11
Client to OBGYN clinic for needle biopsy results. Client provided update on results from
provider. Tumor staging Il based on high potential for lymph node involvement. Client
and provider discussed treatment options for surgical removal of tumor and potential for
chemotherapy and radiation. Client tearful and asks for time to make a treatment
decision.
Nursing Notes.
Health History.
Diagnostic Results
Date
2/10
Diagnostic Study
Diagnostic
Mammogram
2/11
Needle Biopsy
Nurse Statement
“There are many support
groups for women with
Therapeutic
Result/Impression
BI-RADS-4-highly
suggestive of
malignancy, recommend
biopsy
Moderately differentiated
invasive
carcinoma
Non-therapeutic
breast cancer. I can
provide you with contact
information.”
“Let’s identify your family
and friends who will be
your support system
through your treatment.”
“Now you can participate
in those breast cancer
walks and wear beautiful
pink ribbons!”
“At least we caught the
cancer before it spread to
other organs.
That would be more
difficult to treat.”
“Tell me what’s worrying
you right now regarding
your recent diagnosis.”
“Don’t worry, treatment
options have come so far,
and the cure rates get
higher every year.”
“Let me explain exactly
what is involved in the
recovery after surgery so
you are well prepared.”
54. Client states in the past 2 months the firm area has become larger, a bit red, and the
skin near the firm area is dimpling. Client denies any pain in her breast or axillary area.
2/11
Client to OBGYN clinic for needle biopsy results. Client provided update on results from
provider. Tumor staging Il based on high potential for lymph node involvement. Client
and provider discussed treatment options for surgical removal of tumor and potential for
chemotherapy and radiation. Client tearful and asks for time to make a treatment
decision.
2/20
Client admitted for preoperative preparation for lumpectomy surgery today to right
breast with balloon catheter insertion followed by 4 days high dose brachytherapy
inpatient. Provider explained both procedures to client, informed consent witnessed by
RN. Client asks the nurse “Can you go over those procedures again? Details are
calming to me when I feel anxious.”
The nurse cares for the client in the acute oncology department.
For each education topic, click to specify if the nurse should include or not include the
information.
Client Education
Include
“The external radiation
will take up to four weeks
to complete. You may
experience uncomfortable
changes to your skin
exposed to the radiation.”
“The surgeon will biopsy
sentinel lymph nodes
during your surgery to
assess for metastasis of
the cancer.”
“Your right breast will be
removed. Once you are
healed, you can plan
reconst