A nurse on a mental health unit is preparing to document an incident that occurred involving a client. Which of the following considerations by the nurse will ensure competency in the documentation?
The nurse describes what happened by providing general and broad details.
The nurse includes the client's own words when describing what happened.
The nurse describes what happened subjectively.
The nurse includes the opinions of other team members.
The Correct Answer is B
A. The nurse describes what happened by providing general and broad details. Incident reports should be factual, objective, and specific, not general or vague.
B. The nurse includes the client's own words when describing what happened. Including direct quotes from the client ensures accuracy and avoids interpretation or bias.
C. The nurse describes what happened subjectively. Incident reports must be objective, avoiding personal opinions or assumptions.
D. The nurse includes the opinions of other team members. Only document observable facts and direct quotes—opinions should not be included.
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Related Questions
Correct Answer is A
Explanation
A. To create a safe and healing environment for the client: Trauma-informed care (TIC) focuses on providing a supportive, safe, and empowering environment for clients who have experienced trauma. The goal is not to force resolution but to foster trust, autonomy, and recovery.
B. To repair and resolve the client's trauma: While healing may occur, TIC does not aim to "resolve" trauma directly. Instead, it emphasizes understanding the impact of trauma and reducing retraumatization.
C. To focus solely on the client's trauma history: TIC considers the trauma history but also focuses on the present needs, coping strategies, and overall well-being of the client. It does not exclusively dwell on past trauma.
D. To minimize the client's trauma manifestations: The goal is not to suppress trauma symptoms but to acknowledge them, provide appropriate care, and promote a sense of safety and control for the client.
Correct Answer is B
Explanation
A. Avoid eye contact with the client to prevent the client from feeling awkward. Avoiding eye contact may come off as dismissive and can hinder rapport-building.
B. Remain silent after asking the client a question to allow the client a chance to respond. Using therapeutic silence gives the client time to gather their thoughts and feel heard.
C. Ask questions that only require one-word answers to prevent anxiety about answering detailed questions. Open-ended questions encourage communication and help establish trust.
D. Have music on in the background to distract the client from being anxious. Music might be a distraction rather than a rapport-building tool, as it may prevent active listening.
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