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    Ati pn comprehensive predictor 2023 proctored exam

    A nurse is assisting in the care of a client who has schizophrenia. Which of the following entries should the nurse make to follow accurate documentation guidelines?

    Explanation & Rationale

    Rationale: A. The client is admitted due to noncompliance at home: The term "noncompliance" is vague and judgmental. Documentation should focus on specific behaviors or observations (e.g., "client was not taking prescribed medications") rather than generalizing or attributing motives. B. The client uses neologisms when speaking to others: This statement is objective and describes a specific, observable behavior. Using clinical terms to document symptoms of schizophrenia aligns with accurate and professional documentation standards. C. The client is disruptive and annoying to other clients in the facility: This phrasing is subjective and emotionally charged. Accurate documentation should avoid value-laden terms and instead describe the exact behavior (e.g., "client raised voice and interrupted group session"). D. The client's partner is making their symptoms worse: This is speculative and not based on objective observation. Unless the client specifically states this or it is directly witnessed, such assumptions should not be included in medical documentation.

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