A nurse is assisting with a group therapy session and notes a client who remains silent.

Which of the following actions should the nurse take?

Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.

Incorrect:

B- Limit documentation to subjective information: This is an incorrect action to take.

Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.

C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.

D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.

Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.

Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.

Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.

Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.

The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:

Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.

Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.