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.

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.

Limit documentation to subjective information.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: Quoting client comments when documenting provides accurate and direct information. It ensures the client's exact words are recorded, which is important for clear communication among healthcare providers and for legal documentation.

Choice B rationale: Documenting medication administration should occur immediately after giving the dose, not prior. This ensures accuracy and prevents potential errors or omissions, maintaining the integrity and safety of the client's medical record.

Choice C rationale: Documenting information telephoned in by a nurse who left the unit ensures continuity of care. It accurately records details that may be critical to the client's treatment and care plan, ensuring that all healthcare providers have up-to-date information.

Choice D rationale: Limiting documentation to subjective information is not sufficient. Comprehensive documentation should include both subjective (client's statements) and objective (measurable data) information to provide a complete and accurate picture of the client's condition and care.

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Correct Answer is A

Explanation

Choice A rationale:

The appropriate response by the nurse in this situation is to consider the client's request and check with the charge nurse to see if it's possible to adjust the smoke breaks. This response demonstrates a willingness to listen to the client's request and explore the possibility of accommodating their needs within the unit's policies and routines. It does not immediately grant the request but shows respect for the client's concerns and attempts to find a compromise.

Choice B rationale:

Asking the client why they feel extra smoke breaks should be allowed is not the best response. It may come across as confrontational and defensive, which can escalate the situation. Clients with antisocial personality disorder may have difficulty adhering to rules, so it's essential to approach their requests with a collaborative and problem-solving attitude.

Choice C rationale:

Offering an extra smoke break in exchange for participation in group therapy is not an appropriate response. It can be seen as manipulating the client or using rewards to control their behavior. It's essential to maintain clear boundaries and not use rewards or punishments as a means of managing clients with personality disorders.

Choice D rationale:

Telling the client the smoking times on the unit are after each meal is not an appropriate response either. It doesn't address the client's request and simply restates the unit's policy. It's important to engage in a more therapeutic and client-centered approach when responding to requests from individuals with personality disorders.

A. Elevated blood pressure. B. Clammy skin. C. Fruity breath odor. D. Bounding pulse.

Correct Answer is C

Explanation

Choice A rationale:

Elevated blood pressure is not typically associated with diabetic ketoacidosis (DKA) In fact, individuals with DKA often experience low blood pressure due to dehydration.

Choice B rationale:

Clammy skin can occur in DKA due to dehydration and metabolic disturbances, but it is not a specific finding that differentiates DKA from other conditions.

Choice D rationale:

A bounding pulse is not a characteristic finding in DKA. Individuals with DKA may have a rapid pulse due to the stress on the body, but it is not typically described as bounding.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has antisocial personality disorder who requests to smoke outside of scheduled smoke breaks.Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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