The student nurse asks why the nurse is documenting the client's ...

[mcmcdaniel]

The student nurse asks why the nurse is documenting the client's nonverbal responses in addition to verbal responses during the initial assessment.
 
  Which of the following statements made by the nurse reflects the rationale for documenting both verbal and nonverbal responses? 1. It is the hospital policy to document both.
  2. It is important to be thorough when documenting.
  3. Documenting both permits the reader to compare the behaviors for congruence.
  4. Charting verbal and nonverbal helps me remain objective.

Question 2

An adolescent client is attempting to manipulate the nurse into giving a special privilege. The nurse recognizes the manipulation and responds by saying:
 
  1. All the clients must follow the rules.
  2. If I do it for you, I would have to do it for everyone.
  3. If I granted you that privilege, I'd be in trouble
  4. That would not be fair to the others.

[debra928]

Answer to Question 1

3
Rationale: Both verbal and nonverbal behaviors are important to communication. The behaviors are compared to determine if the client's verbal and nonverbal communication are congruent. Nonverbal communication may carry more meaning than verbal communication. It is important to remain objective when documenting; however, the rationale for documenting both is to evaluate congruence. It is important to be thorough when documenting; however, the rationale for documenting verbal and nonverbal responses is to compare for congruence. The rationale for documenting both verbal and nonverbal is to document for congruence, not because it is or is not hospital policy.

Answer to Question 2

1
Rationale: The correct response is to state the expectations for behavior on the unit and be clear that there is no room for exceptions. Stating the rules helps to reinforce the boundaries and prevents the nurse from getting into a power struggle. The other choices (If I granted you that privilege, I'd be in trouble; That would not be fair to the others; and If I do it for you I would have to do it for everyone) are an attempt to induce feelings of guilt and place the decision-making in the power of the adolescent.

[mcmcdaniel]

TYSM

[sultansheikh]

Excellent