The nurse is caring for a client who was recently admitted to the unit. During the nursing assessment of the client, the nurse finds the client's beliefs and actions related to many health practices to stray from the norm
Which action would be most appropriate for the nurse to take at this time? 1. Repeat the assessment later in the day.
2. Write a nursing diagnosis to address the "bizarre" beliefs and actions.
3. Inquire as to the culture with which the client identifies.
4. Communicate the findings to the health care team.
3
Rationale: A thorough assessment is needed before proceeding with other steps of the nursing process. Behavior that is considered bizarre in one cultural context may be considered desirable in another. While findings will be communicated and used for nursing diagnosis formulation, these steps are built upon a thorough assessment. Repeating the assessment will most likely result in the same incomplete data.
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