What should a nurse do after obtaining assessment data from an older client about sleep disturbances?

Documenting the findings in the medical record after assessing an older client for sleep disturbances is essential for several reasons. First, accurate documentation ensures that there is a permanent record of the client's condition, enabling ongoing monitoring and care continuity. It allows other healthcare team members to be aware of the client’s sleep issues and helps in formulating a comprehensive care plan tailored to their needs.

In addition, effective documentation supports communication among the healthcare team. It ensures that the assessment findings are accessible for future reference, aiding in tracking progress or any changes in the client’s condition over time. This step is crucial in geriatric care, where sleep disturbances can significantly impact an older person’s overall health, mood, and cognitive functioning.

By choosing to document rather than take actions like prescribing medication or suggesting stimulants, the nurse ensures that any intervention based on the assessment data will be grounded in a thorough understanding of the client's condition as recorded in their medical history. This approach highlights the importance of evaluating and documenting patient data before implementing interventions.