The nurse is planning to document a patient's response to learning that he will need additional surgery to correct a health problem. Which of the following would be the most appropriate for the nurse to document?

Question

1. Patient was nontalkative and sat in a chair for 4 hours.
2. Patient argued with everyone who came into his room today.
3. Patient was overheard telling his wife to phone his lawyer to sue the hospital.
4. Patient appeared to be angry and had a poor appetite for all meals today.

Answer 1

Patient was nontalkative and sat in a chair for 4 hours.

Rationale: The nurse's observations should be objective and factual. Opinions regarding care or decisions are not appropriate for the legal record; therefore the nurse should not state that the patient was arguing, that he was overhead talking with his wife about an attorney, or how the patient appeared. Documentation of a poor appetite should be more objective and include what was and what was not eaten.