The postmastectomy client scenario, Ms. Scharfe, has been crying, refuses to eat, and will not speak to her husband. Which is the best documentation of this client situation?

The postmastectomy client scenario, Ms. Scharfe, has been crying, refuses to eat, and will not speak to her husband. Which is the best documentation of this client situation?

• A. "Ms. Scharfe shows manifestations of depression."
• B. "Ms. Scharfe is upset due to her mastectomy."
• C. "Ms. Scharfe is crying, refuses food, will not talk to her husband."
• D. "Ms. Scharfe experienced an emotional postop day, with periods of weeping and anorexia due to pain and anaesthetic, and was ignoring her husband."

Answer: (C)

The main idea is to document observable, objective behavior instead of labeling a condition or guessing the cause. The best choice records exactly what can be seen: crying, refusing food, and not speaking to her husband. This is neutral, observable data that the care team can act on and reassess over time. Other options try to diagnose or attribute a cause (depression, upset from the mastectomy, or pain/anaesthetic) without sufficient assessment data. That makes the note interpretive rather than descriptive. By sticking to what’s observable, you keep the record accurate and then can pursue further assessment for depression, emotional distress, pain, or social support as needed.

The main idea is to document observable, objective behavior instead of labeling a condition or guessing the cause. The best choice records exactly what can be seen: crying, refusing food, and not speaking to her husband. This is neutral, observable data that the care team can act on and reassess over time.

Other options try to diagnose or attribute a cause (depression, upset from the mastectomy, or pain/anaesthetic) without sufficient assessment data. That makes the note interpretive rather than descriptive. By sticking to what’s observable, you keep the record accurate and then can pursue further assessment for depression, emotional distress, pain, or social support as needed.