A peer mentions that a new nurse seems to be spending a lot of ...

[FButt]

A peer mentions that a new nurse seems to be spending a lot of time with a young female client.
 
  The
  nurse visits the client before reporting for duty, seeks out the client for interactions during the shift,
  and makes sure to spend a few minutes with the client after going off duty. The new nurse was
  overheard giving the client's nurse therapist opinions about the client and the care plan. Yesterday,
  the new nurse brought the client a gift. Which assessment could be made? The new nurse is
  a. overinvolved.
  b. expressing anger.
  c. experiencing boredom.
  d. looking to be rescued.

Question 2

The nurse writes in the client's progress notes: 3/5/year 10 AM. Client brought to unit by ER nurse.
  Client's clothing and body are dirty. In interview room, client sat with hands over face, sobbing
  softly.
 
  Did not acknowledge nurse and did not reply to questions. After several minutes abruptly
  arose and ran to window and pounded window screen, shouting, Let me out of here' repeatedly.
  Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol po obtained. Medication
  administered with result that client stopped shouting and returned to sit wordlessly in chair. Client
  placed on one-to-one observation until seen by psychiatrist.. How should this documentation be
  evaluated?
  a. Meets agency standards
  b. Contains subjective material
  c. Too brief to be of value
  d. Excessively wordy

[LegendaryAnswers]

Answer to Question 1

ANS: A
There are no data to support options B, C, or D. The nurse behavior described is typical of
overinvolvement.

Answer to Question 2

ANS: A
This narrative note describes client appearance, behavior, and conversation. It mentions that
less-restrictive measures were attempted before administering medication and documents client
response to medication. This note would probably meet agency standards. A complete nursing
assessment would be in order as soon as the client is able to participate. Option B: Subjective
material is absent from the note. Options C and D are inaccurate evaluations based on the
explanation for option A.

[FButt]

Thank you

[LegendaryAnswers]

No problemo