A nurse in a mental health facility is completing an incident report. Which of the following findings should the nurse identify as requiring completion of an incident report?
A client did not receive prescribed medication yesterday.
A client who became aggressive despite limit-setting on their behavior.
A client who missed their therapy session.
A client who has major depressive disorder and refuses to leave their room.
The Correct Answer is A
Choice A reason: Failure to administer prescribed medication is a medication error and must be documented through an incident report. This ensures accountability, promotes safety, and initiates corrective action to prevent recurrence.
Choice B reason: Aggressive behavior may be part of the client’s psychiatric presentation. Unless it results in harm or requires emergency intervention, it may not meet the threshold for an incident report unless facility policy dictates otherwise.
Choice C reason: Missing a therapy session is not typically considered an incident unless it results in harm or is part of a pattern requiring intervention. It should be documented in progress notes, not an incident report.
Choice D reason: Refusal to leave the room may indicate worsening depression but does not constitute an incident unless it leads to harm or safety concerns. It should be addressed in the care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Rheumatoid arthritis is not a contraindication for ECT unless it involves cervical spine instability. It should be assessed but is not an immediate concern.
Choice B reason: Kidney failure requires monitoring of fluid and electrolyte balance but is not a direct contraindication to ECT.
Choice C reason: Congestive heart failure poses a significant risk due to the hemodynamic changes induced by ECT, including sympathetic stimulation and increased cardiac workload. This must be reported and evaluated.
Choice D reason: Diabetes requires glucose monitoring but does not contraindicate ECT unless there are associated cardiovascular complications.
Correct Answer is A
Explanation
Choice A reason: The orientation phase focuses on establishing trust, defining roles, and setting goals collaboratively. This sets the foundation for therapeutic engagement.
Choice B reason: Teaching problem-solving skills is more appropriate during the working phase when interventions are actively implemented.
Choice C reason: Incorporating strategies into daily life occurs later in the relationship, typically during the working or termination phase.
Choice D reason: Evaluation of coping mechanisms is part of the working or termination phase, not the initial orientation phase.
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