Which entry in the medical record will meet the requirement that ...

[TFauchery]

Which entry in the medical record will meet the requirement that the nurse must document with
  problem-oriented charting?
 
  a. A: Client muttering to self as though answering an unseen person. P: Sensory
  perceptual alteration related to internal auditory stimulation. I: Client received prn
  fluphenazine po at 9 AM and went to room to lie down. E: Client calmer by 9:30
  AM. Returned to community room to watch TV..
  b. Agitated behavior. D: Client muttering to self as though answering an unseen
  person. A: Given Haldol 2 mg po and went to room to lie down. E: Client calmer.
  Returned to lounge to watch TV..
  c. S: Client states I feel like I'm ready to blow up.' O: Pacing hall and mumbling
  to self as though answering an unseen person. A: Client is experiencing auditory
  hallucinations. P: Offered prn Haldol 2 mg po. I: 2 mg Haldol po administered. E:
  Client calmer. Returned to lounge and watched TV..
  d. Client seen pacing hall and muttering to self as though answering an unseen
  person. Haldol 2 mg po administered at 9 AM with calming effect in 30 minutes.
  Stated he was no longer bothered by the voices.'

Question 2

Which statement made by a client during the initial assessment interview will provide the nurse with
  the best understanding of the client's current problem and reason for seeking treatment?
 
  a. I can always trust my wife..
  b. You never know who will turn against you..
  c. I've been hearing the voices of my dead parents..
  d. I wish I knew what I've done to deserve such bad luck..

[elyse44]

Answer to Question 1

ANS: C
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective
data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation.
Option A is an example of PIE charting. Option B is an example of focus documentation. Option D
is an example of narrative documentation.

Answer to Question 2

ANS: C
Option C tells the nurse that the client is experiencing auditory hallucinations.
The other statements are vague and do not clearly identify the client's chief symptom.

[TFauchery]

TYSM

[ricroger]

Gracias!