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. An adult client is confined with physical restraints after throwing chairs at other clients and staff. Physical restraints are highly restrictive and should be used as a last resort when safety is at risk.
B. An adolescent is taken to a secure, quiet room after threatening and lashing out at other clients and staff. Seclusion is restrictive but less so than physical restraints; however, other interventions should be attempted first.
C. An 8-year-old child is asked to return to their room after yelling at other children during a group therapy session. This is the least restrictive intervention, as it involves verbal redirection rather than confinement or medication.
D. An adult client is given clozapine, an antipsychotic medication, after punching a wall with their fist and telling everyone that they intend to hurt them. Medication can be restrictive when used for behavior control rather than for medical necessity.
Correct Answer is D
Explanation
A. "You only need to provide a copy to your family." While family members should have a copy, they are not the only ones who need it. Healthcare providers and legal representatives should also have access.
B. "Advance directives are not needed for individuals who have a mental illness." Clients with mental illness can and should have advance directives, especially regarding psychiatric treatment preferences.
C. "Giving you legal advice about advance directives is outside my scope of practice." While nurses cannot provide legal advice, they can educate clients on the importance of advance directives and who should receive a copy.
D. "You should provide a copy to your providers, family members, and lawyer." Advance directives should be shared with healthcare providers, family members, and legal representatives to ensure they are followed in case of a crisis.
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