The nurse writes in the client's progress notes: "3/5/year 10 AM. Client brought to unit by ER nurse
Client's clothing and body are dirty. In interview room, client sat with hands over face, sobbing
softly.
Did not acknowledge nurse and did not reply to questions. After several minutes abruptly
arose and ran to window and pounded window screen, shouting, ‘Let me out of here!' repeatedly.
Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol po obtained. Medication
administered with result that client stopped shouting and returned to sit wordlessly in chair. Client
placed on one-to-one observation until seen by psychiatrist.". How should this documentation be
evaluated?
a. Meets agency standards
b. Contains subjective material
c. Too brief to be of value
d. Excessively wordy
ANS: A
This narrative note describes client appearance, behavior, and conversation. It mentions that
less-restrictive measures were attempted before administering medication and documents client
response to medication. This note would probably meet agency standards. A complete nursing
assessment would be in order as soon as the client is able to participate. Option B: Subjective
material is absent from the note. Options C and D are inaccurate evaluations based on the
explanation for option A.
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Fill in the blank with correct word.