A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply

Question

a. Uncooperative patient
b. Patient's subjective responses
c. Only data obtained from the patient's verbal responses
d. Description of the patient's behavior during the interview
e. Analysis of why the patient is unresponsive during the interview

Answer 1

ANS: B, D
Both the content and process of the interview should be documented. Providing only the patient's verbal responses creates a skewed picture of the patient. Writing that the patient is uncooperative is subjectively worded. An objective description of patient behavior is preferable. Analysis of the reasons for the patient's behavior is speculation, which is inappropriate.