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A nurse is caring for a client in restraints. Which of the following statements are appropriate documentation? (SATA)

A. " Client ate most of his breakfast."
B. "Client was offered 8oz of water every hr."
C. "Client shouted at assistive personnel."
D. "Client received chlorpromazine (Thorazine) 15mg by mouth at 1000."
E. "Client acted out after lunch."

User Evenwerk
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1 Answer

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Final answer:

The appropriate statements for documentation when caring for a client in restraints are B, C, and D, as they provide relevant and specific information about the client's care and condition.

Step-by-step explanation:

The subject of this question is the appropriate documentation for a nurse caring for a client in restraints. From the given options, the appropriate statements for documentation would include:

  • B. "Client was offered 8oz of water every hr." - This demonstrates that the client's hydration needs are being attended to regularly, which is important for their welfare.
  • C. "Client shouted at assistive personnel." - Documenting behavioral issues is crucial as it provides context for the client's emotional state and can inform future care strategies.
  • D. "Client received chlorpromazine (Thorazine) 15mg by mouth at 1000." - Recording the administration of medication, including the dosage and time, is essential for maintaining accurate medical records and ensuring medication safety.

Options A and E are less relevant to the fact they are in restraints and more about the client's behavior and daily activities. When documenting in a medical context, specificity and relevance to the client's current care or condition is vital.

User Jean Waghetti
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