A psychiatric–mental health nurse is documenting information in a client's medical record. Which of the following would be least likely to increase the nurse's legal liability?
A) "Client reported that he was feeling better today than yesterday."
B) "Administered haloperidol 10 mg IM stat as ordered for agitation."
C) "Client was talking with another staff member and started screaming."
D) "Applied restraints to all four client extremities."
Ans: B
The entry about medication administration is the most complete and clear because it states the name of the medication, the dosage and route, and why it was administered. The nurse would then be responsible for following up this documentation with information about how the client responded to the medication. The statement about the client feeling better, and the statement about talking with a staff member and screaming, are both vague and general. The statement about applying restraints is incomplete. The statement needs to include information about why the restraints were applied, that an order was obtained for the restraints, and how the client responded to the restraints.
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