Focused Review:
RN ATI Capstone Proctored Comprehensive Assessment A
Cancer disorders: Planning discharge teaching for a client who is postoperative following a
modified radical mastectomy-AMS Chapter 92
• Modified radical mastectomy: lymph nodes removed
• Nursing Actions:
➢ Have the client sit with the head of the bed elevated 30° when awake and
support her arm on a pillow. Lying on the unaffected side can relieve
pain.
➢ Have the client wear a sling while ambulating (to support arm).
➢ Avoid administering injections, taking blood pressure, or obtaining blood
from the client’s affected arm. Please a sign above the client’s bed
regarding these precautions.
➢ Emphasize the importance of well-fitted breast prosthesis for a client
who had a mastectomy.
➢ Provide emotional support to the client and her family
➢ Encourage the client to express feelings related to perception of sexuality
and body image.
• Client education:
➢ Teach the client how to care for her incision and drainage tubes (drains
are usually left in for 1 to 3 weeks)
➢ Advise the client to avoid placing her arm in a dependent position.
This position will interfere with wound healing.
➢ Encourage early arm and hand exercises (squeezing a rubber ball, elbow
flexion and extension), and hand-wall climbing to prevent lymphedema and
to regain full range of motion
➢ Teach the client not to wear constrictive clothing and to avoid cuts
and injuries on the affected arm.
Continuity of care: Interventions promoting independence- CH Chapter 7
• Community health nurses play a large role in maintaining continuity of care
for clients as they transition from acute to outpatient settings and promote
independence.
• Group partnering to elicit needed change in the community are more powerful than
a nurse working independently with an individual.
• Nursing interventions:
➢ Initiate necessary consults, or notify the provider of the client’s needs so
the provider can initiate a consult.
➢ Seek expertise from health care professionals representing a variety of
disciplines.
, ➢ The nurse educates clients about community resources and self-care
measures
➢ Coordinate all health care services and resources.
Crisis management: Crisis intervention for intimate partner-MH Chapter 29
• A crisis is an acute, time-limited (usually lasting 4 to 6 weeks) event during which a
client experiences an emotional response that cannot be managed with the client’s
normal coping mechanisms.
• Maturational/internal crisis: Achieving new developmental stages, which requires
learning additional coping mechanism
• Crisis intervention is designed to provide rapid assistance for individuals or
groups who have an urgent need
➢ Promote a sense of safety by assessing the client’s potential for suicide
or homicide
➢ Identifying the current problem and directing interventions for resolution
➢ Helping the client to set realistic, attainable goals
➢ Strategies to decrease anxiety
➢ Critical Incident Stress Debriefing is a group approach that can be used
with a group of people who have been exposed to a crisis situation
Facility protocols: Discovering a medication error- Leadership Chapter 5
• Incident reports are records of unexpected or unusual incidents that affected a
client, employee, volunteer, or visitor in a health care facility. In most states, as
long as proper safeguards are employed, incident reports cannot be subpoenaed by
clients or used as evidence in lawsuits.
• Medication errors, procedures/treatment errors, equipment-related injuries/errors,
needle stick injuries, client falls/injuries, visitor/volunteer injuries, threat made to
client or staff, loss of property.
• In the event of an incident that involves a client, employee, volunteer, or visitor,
the nurse’s priority is to assess the individual for injuries and institute any
immediate care measures necessary to decrease further injury. If the incident
was client-related, notify the provider and implement additional tests or
treatment as prescribed.
Care of special populations: Recommending appropriate referrals- CH Chapter 5
• Community health nurses can link vulnerable clients to relevant resources.
• Assist in removing or reducing factors that contribute to stress by referring
caretakers of older adult clients to respite services, assisting an unemployed parent
RN ATI Capstone Proctored Comprehensive Assessment A
Cancer disorders: Planning discharge teaching for a client who is postoperative following a
modified radical mastectomy-AMS Chapter 92
• Modified radical mastectomy: lymph nodes removed
• Nursing Actions:
➢ Have the client sit with the head of the bed elevated 30° when awake and
support her arm on a pillow. Lying on the unaffected side can relieve
pain.
➢ Have the client wear a sling while ambulating (to support arm).
➢ Avoid administering injections, taking blood pressure, or obtaining blood
from the client’s affected arm. Please a sign above the client’s bed
regarding these precautions.
➢ Emphasize the importance of well-fitted breast prosthesis for a client
who had a mastectomy.
➢ Provide emotional support to the client and her family
➢ Encourage the client to express feelings related to perception of sexuality
and body image.
• Client education:
➢ Teach the client how to care for her incision and drainage tubes (drains
are usually left in for 1 to 3 weeks)
➢ Advise the client to avoid placing her arm in a dependent position.
This position will interfere with wound healing.
➢ Encourage early arm and hand exercises (squeezing a rubber ball, elbow
flexion and extension), and hand-wall climbing to prevent lymphedema and
to regain full range of motion
➢ Teach the client not to wear constrictive clothing and to avoid cuts
and injuries on the affected arm.
Continuity of care: Interventions promoting independence- CH Chapter 7
• Community health nurses play a large role in maintaining continuity of care
for clients as they transition from acute to outpatient settings and promote
independence.
• Group partnering to elicit needed change in the community are more powerful than
a nurse working independently with an individual.
• Nursing interventions:
➢ Initiate necessary consults, or notify the provider of the client’s needs so
the provider can initiate a consult.
➢ Seek expertise from health care professionals representing a variety of
disciplines.
, ➢ The nurse educates clients about community resources and self-care
measures
➢ Coordinate all health care services and resources.
Crisis management: Crisis intervention for intimate partner-MH Chapter 29
• A crisis is an acute, time-limited (usually lasting 4 to 6 weeks) event during which a
client experiences an emotional response that cannot be managed with the client’s
normal coping mechanisms.
• Maturational/internal crisis: Achieving new developmental stages, which requires
learning additional coping mechanism
• Crisis intervention is designed to provide rapid assistance for individuals or
groups who have an urgent need
➢ Promote a sense of safety by assessing the client’s potential for suicide
or homicide
➢ Identifying the current problem and directing interventions for resolution
➢ Helping the client to set realistic, attainable goals
➢ Strategies to decrease anxiety
➢ Critical Incident Stress Debriefing is a group approach that can be used
with a group of people who have been exposed to a crisis situation
Facility protocols: Discovering a medication error- Leadership Chapter 5
• Incident reports are records of unexpected or unusual incidents that affected a
client, employee, volunteer, or visitor in a health care facility. In most states, as
long as proper safeguards are employed, incident reports cannot be subpoenaed by
clients or used as evidence in lawsuits.
• Medication errors, procedures/treatment errors, equipment-related injuries/errors,
needle stick injuries, client falls/injuries, visitor/volunteer injuries, threat made to
client or staff, loss of property.
• In the event of an incident that involves a client, employee, volunteer, or visitor,
the nurse’s priority is to assess the individual for injuries and institute any
immediate care measures necessary to decrease further injury. If the incident
was client-related, notify the provider and implement additional tests or
treatment as prescribed.
Care of special populations: Recommending appropriate referrals- CH Chapter 5
• Community health nurses can link vulnerable clients to relevant resources.
• Assist in removing or reducing factors that contribute to stress by referring
caretakers of older adult clients to respite services, assisting an unemployed parent
