A group of nurses is discussing the purpose of mental health documentation. Which of the following descriptions of nursing documentation for a mental health client is accurate?
Documentation for a mental health client is a defined process based on hospital specific requirements which highlights client care.
Documentation for a mental health client is focused on the client's diagnosis, reason for medications, plan of care, and client progression.
Documentation for mental health clients provides a record of the nurse's awareness of client behaviors, mental status, interventions, and client response.
Documentation for a mental health client outlines the client's therapies, treatments, and needs for discharge planning.
The Correct Answer is C
A. Documentation for a mental health client is a defined process based on hospital-specific requirements which highlights client care. While hospitals have policies, documentation must follow legal and ethical guidelines beyond just facility rules.
B. Documentation for a mental health client is focused on the client’s diagnosis, reason for medications, plan of care, and client progression. Documentation includes more than just diagnosis and medication, such as behavior observations, interventions, and responses.
C. Documentation for mental health clients provides a record of the nurse’s awareness of client behaviors, mental status, interventions, and client response. Comprehensive mental health documentation includes behaviors, mental status, interventions, and outcomes.
D. Documentation for a mental health client outlines the client’s therapies, treatments, and needs for discharge planning. This is part of the documentation but does not capture all aspects of mental health nursing records.
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Related Questions
Correct Answer is D
Explanation
A. Avoid including the client's religious affiliation when discussing treatment options. Religious beliefs can impact medical decisions, so omitting this information could overlook important care considerations.
B. Include each piece of collected demographic data during change-of-shift report. Not all demographic data are relevant to patient care, and oversharing may lead to unnecessary biases.
C. Record the client’s spirituality as normal in the plan of care. Spirituality is personal and subjective, so labeling it as “normal” is inappropriate and not bias-free.
D. Provide relevant demographics during a treatment team meeting. This ensures demographic information is included only when it impacts care, avoiding bias while maintaining patient-centered treatment.
Correct Answer is D
Explanation
A. "Reinforce the importance of treatment to a client who speaks a language different from the nurse." Effective communication requires using an interpreter rather than reinforcing information in a language the client may not understand.
B. "Minimize contact with a client who is angry." Avoiding an angry client can damage trust. The nurse should use therapeutic communication techniques to address their concerns.
C. "Use clinical terminology to help a client better understand their diagnosis." Clinical terminology can be confusing. The nurse should use simple, clear language to explain medical concepts.
D. "Fulfill a promise by allowing a client to visit with family members." Keeping promises builds trust and demonstrates reliability, a key component of the nurse-client relationship.
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