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 A
Explanation
Rationale:
A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.
B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.
C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.
D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.
Correct Answer is B
Explanation
Rationale:
A. "I will follow a full-liquid diet the day before the procedure.": Clients are typically instructed to follow a clear-liquid, not full-liquid, diet the day before a colonoscopy. Clear liquids like broth, gelatin, and clear juice help ensure the colon is clean for optimal visualization.
B. "I'll have my friend drive me home after the procedure.": Sedation is usually administered during a colonoscopy, which impairs alertness and coordination. Having a responsible adult to drive the client home is necessary and reflects appropriate understanding of post-procedure safety.
C. "I can expect rectal bleeding for a week after the procedure”: Rectal bleeding after a colonoscopy is not expected and could indicate complications such as a perforation or polyp removal site bleeding. Any persistent or heavy bleeding should be reported immediately.
D. "This procedure will take place while I’m under general anesthesia.”: Colonoscopies are generally performed under moderate (conscious) sedation, not general anesthesia. Clients remain semi-awake but relaxed and unaware, making this statement inaccurate.
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