On assessment, the nurse identifies that the client is quiet, tearful, and withdrawn. The client says, "I don't want to eat breakfast this morning. I would rather stay in bed." How should the nurse document this assessment?
1. Client is not social today.
2. Client demonstrates a depressed affect.
3. Client is in a bad mood today.
4. Client is uncooperative today.
2
Rationale 1: The client interacted with the nurse, which is a social encounter.
Rationale 2: Affect, the external expression of the client's mood, can be assessed by observation and analysis of statements. "Depressed affect" is the most accurate and specific way to document the nurse's observation.
Rationale 3: Mood is an internal feeling that is externally expressed by affect. "Bad mood" is not the best way to document the nurse's observation.
Rationale 4: There is no evidence that the client is uncooperative. The client has stated a personal desire to skip breakfast and stay in bed.
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