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 B
Explanation
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.
Correct Answer is B
Explanation
A. "Allow the client's family to attend all group therapies with the client." While family involvement can be beneficial, a client’s autonomy and confidentiality must be respected. Some clients may not feel comfortable sharing in the presence of family members.
B. "Listen attentively to a client and summarize their comments." Active listening and summarization demonstrate empathy and understanding, reinforcing the therapeutic relationship. This technique also helps ensure that the nurse accurately understands the client's concerns.
C. "Asking questions easily answered with one-word responses is important with mental health clients." Closed-ended questions limit the client’s ability to express emotions and thoughts, which can hinder the therapeutic process. Open-ended questions encourage meaningful discussion.
D. "Avoid asking clients direct questions regarding suicidal behaviors or thoughts." It is essential to directly ask about suicidal thoughts in a nonjudgmental manner. Avoiding these questions can lead to missed warning signs and inadequate intervention.
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