The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?
Explanation & Rationale
A. Appears confused and depressed. This statement is subjective and makes an assumption about the client's emotional state without concrete evidence. It is better to document objective observations. B. Wandering behavior with flat affect. This is the best choice because it describes specific behaviors (wandering) and observable signs (flat affect) without making assumptions about the client's mental state. C. Ambulatory and disoriented to place. While "ambulatory" is accurate, "disoriented to place" makes an assumption about the client's mental status that may not be verified. D. Demonstrates signs of early dementia. This choice implies a diagnosis which cannot be made based on the described observations alone. Diagnosis should be left to a healthcare provider after a thorough evaluation.