Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?
1. "Client was angry because breakfast was not to her liking."
2. "Client is depressed; was observed crying while alone in room."
3. "Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists."
4. "Client was verbally abusive to staff when approached concerning client's con-tinued attempts to smoke in the bathroom."
ANS: 2
Do not write personal opinions. Document observable, measurable client-oriented data only. Re-cording that the client is depressed based on the observation of tears is not objective and so is not acceptable. While one option does report only observable, measurable behavior, the remaining options, while noting observed client behavior, do fail to objectively describe the noted client behavior.
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