Author Question: Which entry in the medical record will meet the requirement that the nurse must document with ... (Read 54 times)

TFauchery · **on:** Jul 19, 2018

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 · **Reply #1 on:** Jul 19, 2018

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.