Level: Clinical
Difficulty: Medium
Subtopic: Psychosis
NCLEX: A 31-year-old client on an inpatient psychiatric unit is being evaluated for auditory hallucinations. Assessment…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 31-year-old client on an inpatient psychiatric unit is being evaluated for auditory hallucinations. 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. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: A. 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.