Level: Foundational
Difficulty: Easy
Subtopic: Mood disorders
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for major depressive symptoms. Asse…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for major depressive symptoms. Assessment data include the client is pacing aggressively, clenching fists, and refusing to sit. 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.