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A charge nurse is reviewing documentation in the medical record from a Click to highlight the findings that indicate this nurse requires additional newly licensed nurse. education. To deselect a finding, click on the finding again. Admission Assessment Provider Prescriptions Nurses’ Notes Nurses’ Note Admission Assessment 2130: Client has a history of major depressive disorder and alcohol use disorder. 1800: They have had previous hospitalization which has included detoxification. Client is inappropriate and is a huge fall risk. Provider has denied this RN’s requests for physical or chemical restraints. Currently, ICU and progressive Client is admitted to the emergency department following a motor care unit are full, and client is being admitted to this medical unit. They vehicle accident with a broken tibia. Client states pain is at an 8 on a pain appear ‘medically stable.’ Client is alert, oriented to self and location. Denies scale of 0 to 10. Morphine 10 mg IV given orally. Client’s partner reports pain. Sitting up in bed. The client’s partner is at bedside and said that their the client has been depressed and drinking excessively. Client’s leg was spouse is always complaining or arguing. casted before client was transferred to medical unit.

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