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 C

Explanation

Rationale:

A. Restrict alcohol intake to 350 mL (12 oz) of wine per day: This recommendation exceeds the safe alcohol limit for individuals at risk for hypertension. For women, the limit is typically one drink per day, and for men, up to two.

B. Limit caloric intake to 2,500 calories per day: 2,500 calories may still be excessive for many individuals, especially those with sedentary lifestyles. Hypertension risk is more effectively reduced through balanced nutrition and physical activity, not just calorie limits.

C. Walk for 30 min 5 days per week: Regular aerobic exercise like walking improves cardiovascular health and is strongly recommended to prevent and manage hypertension. This frequency and duration align with guidelines to lower blood pressure and support overall wellness.

D. Increase dietary intake of canned vegetables: Canned vegetables often contain high sodium levels, which can contribute to elevated blood pressure. Clients at risk for hypertension should be encouraged to choose fresh or low-sodium alternatives to help control sodium intake.

A. Positions the client in a chair before applying the stockings B. Elevates the legs before applying the stockings C. Rolls the extra stocking material down to the client's knee D. Massages the legs before applying the stockings

Correct Answer is B

Explanation

Rationale:

A. Positions the client in a chair before applying the stockings: Applying antiembolic stockings while the client is in a seated position may lead to venous pooling in the lower extremities. This reduces the effectiveness of the stockings and may cause improper fit or increased pressure in dependent areas.

B. Elevates the legs before applying the stockings: Elevating the legs allows venous blood to drain from the lower extremities, reducing swelling and promoting proper application of the stockings. This ensures the stockings provide even compression and help prevent complications like thrombus formation.

C. Rolls the extra stocking material down to the client's knee: Rolling down the stockings creates a tourniquet effect, which can impair circulation and increase the risk of complications like venous stasis or skin breakdown. Stockings should be smooth and free of folds.

D. Massages the legs before applying the stockings: Massaging the legs, especially in a client with phlebitis, may dislodge a clot if present and increase the risk of embolism. Gentle handling without vigorous massage is essential in clients at risk for thromboembolic events.

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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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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is at risk for hypertension. Which of the following risk reduction strategies should the nurse Include in the teaching?

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Explanation

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Correct Answer is B

Explanation

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