The nurse records this entry in a patient's progress notes: ...

[bclement10]

The nurse records this entry in a patient's progress notes:
 
  Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, Let me out of here. Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation.
   How should this documentation be evaluated?
 
  a. Uses unapproved abbreviations
  b. Contains subjective material
  c. Too brief to be of value
  d. Excessively wordy
  e. Meets standards

Question 2

A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurse's next comment?
 
  a. How did you get to the United States?
  b. Would you like for a family member to help you talk with me?
  c. An interpreter is available. Would you like for me to make a request for these services?
  d. Are you comfortable conversing in English, or would you prefer to have a translator present?

[dominiqueenicolee]

Answer to Question 1

ANS: E
This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.

Answer to Question 2

ANS: D
The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient's responses; a translator is a better resource.

[bclement10]

Thank you

[dominiqueenicolee]

No problemo