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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Veracity: Veracity refers to the obligation to tell the truth and provide accurate information. While withholding information could also violate this principle, the core issue in this scenario centers more on the client's right to make informed decisions rather than truth-telling alone.
B. Fidelity: Fidelity involves keeping promises and maintaining trust in the nurse-client relationship. While failing to inform the client may strain trust, the request from the parent specifically violates the client's right to participate in decisions about their care.
C. Autonomy: Autonomy is the right of individuals to make informed decisions about their own healthcare. Withholding information about medication side effects directly interferes with the client’s ability to provide informed consent, violating this fundamental ethical principle.
D. Justice: Justice involves fairness and equality in the distribution of care and resources. This principle is not directly implicated in the scenario, as the issue is not about fairness but about the individual’s right to know and decide.
Correct Answer is B
Explanation
Rationale:
A. Apply a warm compress: Applying a warm compress may help promote absorption of infiltrated fluid and reduce discomfort, but it should not be the initial action. Warm compresses are appropriate only after the infusion is stopped and proper assessment is completed.
B. Stop the infusion: The first priority when infiltration is suspected—evidenced by cool, edematous skin—is to stop the infusion immediately. Continuing the infusion could lead to worsening tissue damage or complications depending on the type of fluid or medication.
C. Document the infiltration: Documentation is necessary but not the immediate priority. It should follow prompt clinical action to stop the infusion and prevent further harm to the surrounding tissue.
D. Elevate the arm: Elevating the arm can help reduce edema, but this supportive measure should be done only after the infusion has been stopped. It does not address the root cause or prevent further infiltration.
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