The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview?
A. "Appears uncooperative. Exhibits characteristics of depression."
B. "Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression."
C. "States ‘I don't need to be here' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission."
D. "Unwilling to respond openly during interview."
ANS: C
Documentation occurs in the implementation phase of the nursing process. All charting entries to the client's legal record should be objective and based on assessed data. Implications and generalizations should be avoided.
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