Level: Clinical
Difficulty: Medium
Subtopic: Substance use disorders
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for alcohol withdrawal risk. Assessment da…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for alcohol withdrawal risk. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. 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.