As part of a focused assessment, the nurse asked the client to describe her mood this morning. In response, the client stated, "It is what it is." Which of the following examples of nursing documentation is most appropriate?
A) "Client is nonspecific about her mood."
B) "Client states about her mood, 'It is what it is.'"
C) "Client is currently feeling ambivalent."
D) "Client feels resigned to her symptoms of depression."
Ans: B
When documenting assessment findings, it is important to use the client's own words whenever possible. Subjectively describing a client's mood or speculating about underlying meanings is inappropriate and potentially inaccurate.
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The home care nurse is about to administer intravenous medication to the client and reads in the chart that the PICC line in the client's left arm has been in place for 4 weeks. The IV is patent, with a good blood return
The site is clean and free from manifestations of infiltration, irritation, and infection. What is the nurse's best action? A. Notify the physician. B. Document the findings; administer the prescribed medication. C. Discontinue the PICC line; save the tip aseptically for culture; restart the IV at a new site. D. Switch the medication to the oral route; arrange for the client to have an x-ray to ascertain the PICC location.
A patient scheduled for a laparoscopic cholecystectomy in 4 days asks how pain can be controlled until the surgery. How should the nurse respond?
1. "You will feel better if you sit in a recliner and drink water and try not to eat anything. Do not eat any fat." 2. "You will feel better if you rest in bed and do not eat anything until the procedure. Drink only water and milk." 3. "You will feel better if you alternate lying on your back and lying on your abdomen. You may eat anything except fatty food." 4. "You will feel better if you walk as frequently as possible. You may drink coffee, but not soda."
When communicating with a client diagnosed with a serious mental disorder, it is important for the nurse to recognize which of the following?
a. Clients with mental disorders never have intact sensory channels b. Clients with a ‘flat affect' are easier to understand c. Clients with mental disorders are always very talkative d. Clients with mental disorders may suffer from social isolation and impaired coping
A patient who has HIV infection will begin treatment with efavirenz. The nurse expects this agent to be given in the combination product Atripla in order to
a. avoid development of psychiatric comorbidities. b. prevent dizziness, sedation, and nightmares. c. reduce viral resistance. d. prevent severe rash and hepatotoxicity.