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 C
Explanation
A. Taking on extra shifts to compensate for staffing issues. Overworking increases stress and exhaustion, contributing to burnout rather than preventing it. Nurses need adequate rest to provide quality care.
B. Neglecting to seek support from colleagues and supervisors. Avoiding support leads to isolation and increased emotional distress. Seeking help from colleagues, supervisors, or mental health professionals is crucial in managing stress.
C. Maintaining a balanced diet and regular exercise. Proper nutrition, physical activity, and self-care help nurses maintain physical and mental well-being, reducing burnout risk.
D. Avoiding self-care activities to focus solely on work. Self-care is essential for long-term resilience in nursing. Ignoring personal well-being to prioritize work leads to exhaustion and decreased job satisfaction.
Correct Answer is C
Explanation
A. “Clients must always have a family member present during treatment to ensure their rights are protected.” Clients have the right to privacy and do not require a family member’s presence for treatment unless legally mandated (e.g., minors).
B. "Clients cannot be discharged without their consent, even if they are no longer a risk to themselves or others." Clients can be discharged when they are no longer a risk, even if they disagree, unless under a legal hold.
C. "Clients have the right to refuse medication unless a court order mandates it." Clients have the right to refuse treatment unless a court order requires medication for safety or competency.
D. "All client interactions must be recorded, even if they are informal and unrelated to their care plan." Only relevant, objective, and care-related information should be documented, as excessive documentation can violate privacy.
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