Which nursing documentation best meets the requirement for ...

[RYAN BANYAN]

Which nursing documentation best meets the requirement for problem-oriented charting?
 
  a. Pacing and muttering to self. Sensory perceptual alteration related to internal auditory stimulation. Given fluphenazine 2.5 mg PO at 0900 and went to room to lie down. Calmer by 0930 . Returned to lounge to watch TV.
  b. Agitated behavior. Patient muttering to self as though answering an unseen person. Given haloperidol 2 mg PO and went to room to lie down. Patient calmer within 30 minutes. Returned to lounge to watch TV.
  c. S: States I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg PO. I: Haloperidol 2 mg PO given at 0900 . E: Returned to lounge at 0930 and quietly watched TV.
  d. Pacing hall and muttering to self as though answering an unseen person. Haloperidol 2 mg PO administered at 0900, with calming effect in 30 minutes. Stated I'm no longer bothered by the voices.'

Question 2

A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures to produce a specified weekly weight gain?
 
  a. Severe anxiety concerning eating is expected, so objective and subjective data must be routinely collected.
  b. Patient involvement in decision making increases sense of control and promotes adherence.
  c. Because of risks of physical problems from refeeding, the patient's consent is essential.
  d. A team approach to treatment planning ensures that physical and emotional needs are met.

[nguyenhoanhat]

Answer to Question 1

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. The distracters use PIE, focus, and narrative documentation.

Answer to Question 2

B
A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Consent for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.