A nurse is assisting in the care of a client who has schizophrenia. Which of the following entries should the nurse make to follow accurate documentation guidelines?

The client is admitted due to noncompliance at home.

The client uses neologisms when speaking to others.

The client is disruptive and annoying to other clients in the facility.

The client's partner is making their symptoms worse.

Answer and Explanation

The Correct Answer is B

Rationale:

A. The client is admitted due to noncompliance at home: The term "noncompliance" is vague and judgmental. Documentation should focus on specific behaviors or observations (e.g., "client was not taking prescribed medications") rather than generalizing or attributing motives.

B. The client uses neologisms when speaking to others: This statement is objective and describes a specific, observable behavior. Using clinical terms to document symptoms of schizophrenia aligns with accurate and professional documentation standards.

C. The client is disruptive and annoying to other clients in the facility: This phrasing is subjective and emotionally charged. Accurate documentation should avoid value-laden terms and instead describe the exact behavior (e.g., "client raised voice and interrupted group session").

D. The client's partner is making their symptoms worse: This is speculative and not based on objective observation. Unless the client specifically states this or it is directly witnessed, such assumptions should not be included in medical documentation.

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Correct Answer is B

Explanation

Rationale:

A. Orange juice: Orange juice contains minimal sodium and is typically recommended for clients needing low-sodium, high-potassium diets. It is not considered a significant source of sodium.

B. Canned green beans: Canned vegetables often contain added salt as a preservative, making them high in sodium. Unless labeled as low-sodium or no-salt-added, canned green beans are among the higher sodium food options.

C. Sweet potato: Sweet potatoes are naturally low in sodium and are more commonly recognized for their potassium and fiber content. They are suitable for low-sodium diets.

D. Cantaloupe: Cantaloupe is a low-sodium fruit, valued for its high water and potassium content. It is not a source of concern for clients with sodium restriction or imbalance.

A. "I should gain half of a pound per week to meet my treatment goal’ B. "The staff will watch me closely for 1 hour after each meal’ C. "The treatment goal is to be within 60 percent of my ideal body weight." D. "The staff will weigh me every night before I go to bed."

Correct Answer is B

Explanation

Rationale:

A. "I should gain half of a pound per week to meet my treatment goal": Weight gain goals for clients with anorexia nervosa are typically more aggressive, often around 1 to 3 pounds per week, to restore healthy weight timely and prevent complications of prolonged malnutrition.

B. "The staff will watch me closely for 1 hour after each meal": Monitoring clients after meals is essential to prevent purging behaviors, such as vomiting or excessive exercise. The one-hour observation period helps ensure safety and supports recovery.

C. "The treatment goal is to be within 60 percent of my ideal body weight.": Treatment aims to restore clients to at least 85 to 90 percent of their ideal body weight to improve physical and psychological health; 60 percent is dangerously low and not an appropriate goal.

D. "The staff will weigh me every night before I go to bed.": Weighing is typically done once in the morning before breakfast and after voiding, to ensure consistency and accuracy. Nighttime weighing is not standard practice and may contribute to anxiety.

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A nurse is assisting in the care of a client who has schizophrenia. Which of the following entries should the nurse make to follow accurate documentation guidelines?

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