A young female client is admitted to the emergency department because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record (EMR) as the client’s chief concern?

 

 

Choice A reason: Journaling and self-reflection are useful but may overwhelm a depressed client who lacks motivation. Regular nurse-client interaction provides consistent support, fostering trust and engagement, which is more immediate for inpatient care. This intervention is secondary, making it incorrect for demonstrating primary support.

Choice B reason: Animated communication may be inappropriate for depression, where clients often feel withdrawn. Regular interaction with a calm, supportive presence better addresses the client’s need for connection. Animated techniques risk alienating the client, making this incorrect for demonstrating effective support in major depressive disorder.

Choice C reason: Identifying depression symptoms is part of assessment, not ongoing support. Scheduled interactions build therapeutic rapport, directly addressing the client’s emotional needs in depression. Symptom identification is less supportive than consistent presence, making this incorrect for the primary intervention to demonstrate support.

Choice D reason: Scheduling regular interactions demonstrates support by providing consistent, empathetic engagement, countering the isolation of depression. This fosters trust and therapeutic alliance, critical for inpatient psychiatric care, aligning with nursing principles for major depressive disorder management, making it the most effective intervention for support.

Choice A reason: Controlling the unit reflects grandiosity or mania, not paranoia. Paranoid clients are more likely to exhibit hostility due to perceived threats. This behavior is less typical of paranoia’s suspicious nature, making it incorrect for expected behavior in a paranoid client.

Choice B reason: Open hostility for no apparent reason is common in paranoia, as clients misinterpret others’ actions as threatening due to delusional beliefs. This aligns with psychiatric descriptions of paranoid behavior, making it the most expected behavior for a client with paranoia during assessment.

Choice C reason: Repeated suicide attempts are associated with depression or borderline personality disorder, not primarily paranoia. Hostility from perceived threats is more characteristic of paranoia, making suicide attempts less expected and incorrect for the typical behavior in this client.

Choice D reason: Talking to voices suggests hallucinations, more common in schizophrenia with auditory hallucinations than in paranoia alone. Hostility from suspicion is a more direct paranoid behavior, making this incorrect, as hallucinations are not the primary expected feature of paranoia.