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
The nurse needs to note the source of the patient health history
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