Author Question: An adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? ... (Read 85 times)

gbarreiro · **on:** Jul 19, 2018

An adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? You'll just tell my parents whatever you find out. Select the nurse's best reply.

a. That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know.
b. Yes, your parents may find out what you say, but it is important that they know about your problems.
c. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.
d. It sounds as though you are not really ready to work on your problems and make changes.

Question 2

Which entry in the medical record best meets the requirement for problem-oriented charting?

a. A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.
b. S: States, I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV.
c. Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV.
d. Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, I'm no longer bothered by the voices.'

katieost · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: C
The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The first response is not strictly true. The second response will not inspire the confidence of the patient. The fourth response is confrontational.

Answer to Question 2

ANS: B
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. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.