Level: Advanced
Difficulty: Hard
Subtopic: Sleep and rest
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to sleep and rest….
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 76-year-old client in a long-term care facility is being evaluated for nursing care related to sleep and rest. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which documentation should the nurse record to best support safe care and communication?
Question
A. "Client fine; no changes noted."
B. Copied yesterday's note without updating current assessment data.
C. Subjective opinions only without measurable findings.
D. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
B. Copied yesterday's note without updating current assessment data.
C. Subjective opinions only without measurable findings.
D. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Rationale
Correct answer: D. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.