Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?
1. “Client was angry because breakfast was not to her liking.”
2. “Client is depressed; was observed crying while alone in room.”
3. “Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists.”
4. “Client was verbally abusive to staff when approached concerning client’s con-tinued attempts to smoke in the bathroom.”
ANSWER
ANS: 3
Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objec-tively describe the noted client behavior.
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