Level: Foundational
Difficulty: Easy
Subtopic: Suicide risk
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for expressions of hopelessness. Assessm…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for expressions of hopelessness. Assessment data include the client is withdrawn, flat affect, and refusing meals for 2 days. Which documentation should the nurse record to best support safe care and communication?
Question
A. "Client fine; no changes noted."
B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: B. 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.