A nurse is reviewing the guidelines for documenting client care.

Which of the following actions should the nurse plan to take?

Avoid quoting client comments when documenting.

Limit documentation to subjective information.

Document giving a dose of pain medication just prior to administration.

Document information telephoned in by a nurse who left the unit for the day.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

Speaking to the client at an increased volume in (option C) is not an effective solution for a language barrier. Simply speaking louder will not address the issue of language comprehension. It is important to use appropriate communication strategies, such as seeking a qualified interpreter or using visual aids or gestures to facilitate understanding.

B. Ask a family member of the client to interpret

Using a family member as an interpreter can lead to miscommunication, lack of confidentiality, and potential biases. A professional interpreter should be used to ensure accurate communication. However, in the absence of a professional interpreter, having a family member interpret can help create an understanding between the nurse and the client.

Rest in (option A) is not an appropriate action in this situation. The nurse should actively seek a way to communicate effectively with the client to ensure safe and appropriate care.

Assuming that the client nodding indicates an understanding of the information in (option D) is not reliable. Nodding can have different cultural interpretations and may not always indicate comprehension. It is important to use other means of communication to confirm understanding, such as using a professional interpreter or utilizing visual aids.

A. Suggest the client exercise before going to bed. B. Recommend the client spend time alone in his room. C. Encourage the client to use positive self-talk. D. Offer the client low-protein snacks throughout the day.

Correct Answer is C

Explanation

Helping the client develop positive self-talk and challenging negative thoughts can be beneficial in managing depressive symptoms. Assisting the client in recognizing negative self-perceptions and replacing them with more positive and realistic thoughts can help improve mood and self-esteem.

Exercise has been shown to have mood-enhancing effects and can help alleviate symptoms of depression. However, exercise should be done earlier in the day rather than right before bedtime, as it can have stimulating effects that may interfere with sleep.

It is important to encourage the client to engage in activities and spend time with others. Isolation and spending excessive time alone can exacerbate depressive symptoms. However, it is also important to respect the client's need for privacy and personal space.

While diet does play a role in overall well-being, there is no specific evidence to support the use of low-protein snacks for the treatment of major depressive disorder. It is important to provide the client with a well-balanced diet that includes a variety of nutrients to support overall health.

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A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is reviewing the guidelines for documenting client care.

Which of the following actions should the nurse plan to take?